Low-Dose Proton Beam Therapy for Circumscribed Choroidal Hemangiomas

Abstract

To evaluate the efficacy and safety of proton beam therapy for complicated circumscribed choroidal hemangiomas. Methods: The study was a retrospective nonrandomized investigation. Seventeen consecutive patients, referred to the Institut Gustave-Roussy, Villejuif, France, for circumscribed choroidal hemangioma associated with serous retinal detachment were studied. Each eye received a total dose of 20 cobalt gray equivalents (CGEs) delivered in 15-second fractions of 5 CGEs over 4 days. Functional tests included the initial and final bestcorrected visual acuity, slitlamp examination, intraocular pressure, fundus examination, fluorescein angiography, and indocyanine green angiography. Tumor thickness was determined on B-scan ultrasonography. Results: The macula was involved in 7 eyes and the lesion was juxtapapillary in 2 eyes. The mean (SD) tumor thickness was 3.06 (9.0) mm. The mean initial tumor diameter was 6.82 mm (range, 3.2-12.1 mm). The right eye was involved in 7 cases and the left eye in 10 cases. The mean (SD) follow-up period was 52 (58) months (range, 36-90 months). Retinal reattachment was obtained in all cases after a mean period of 2 months (range, 1-12 months; median, 1 month). Tumor regression was obtained in all cases. One recurrence occurred 1 year after the initial treatment in an undertreated area. After re-treatment, however, resolution of the retinal detachment occurred, and flattening of the choroidal lesion was obtained. Final visual acuity improved to 2 Snellen lines or more in 16 eyes (94%), was stable in 1 eye, and attained 20/40 or more in 12 eyes (70.6%). No radiation therapy complications occurred during follow-up. Conclusions: Proton beam therapy for choroidal hemangiomas seems to be an effective and safe alternative option. A total dose of 20 CGEs delivered in 4 daily 15second fractions of 5 CGEs seems adequate for local control of both the tumor and serous retinal detachment.

Circumscribed choroidal hemangioma

“…[65] EBRT treats the entire choroid with a homogeneous dose of radiation. [63] In the largest series of choroidal hemangiomas treated with EBRT, subretinal fluid resolved in 63.8% and visual acuity was stable or improved in 78% of patients. [66] Ritland et al reported tumor regression in all nine treated eyes with EBRT.…”

“…Plaque brachytherapy allows more targeted treatment of the hemangioma, minimizing radiation-induced side effects but the dose is not homogeneous with higher doses at the tumor base than the apex. [63,67] Plaque radiotherapy is usually used for choroidal hemangioma with extensive subretinal fluid in which PDT would not be advised. Low-dose treatment is sufficient using 20 Gy apex dose.…”

“…[72] In 2004, at 2-year follow-up, 94% of patients treated by Frau et al with proton beam radiation had visual acuity improvement of two or more lines, and 65% of subjects showed complete tumor resolution. [63] Zografos et al [73] reported a series of 48 eyes with circumscribed choroidal hemangioma treated with a radiation dose ranging from 16.4 to 27.3 Gy and all of the patients had resolution of exudative retinal detachment but three patients treated with 27.3 Gy developed optic neuropathy.…”

Photodynamic therapy: current role in the treatment of chorioretinal conditions

“…33 Radiation therapy remains a useful treatment modality for larger choroidal haemangiomas with extensive exudative retinal detachment that are not amenable to vPDT therapy. 39 There is, however, a risk of radiationinduced complications (cataract, radiation retinopathy and optic neuropathy). Diffuse choroidal haemangiomas associated with Sturge-Weber syndrome can be treated by vPDT therapy, 40 though radiation therapy may be required for more severe cases.…”

Proton Beam Irradiation Using a Light-Field Technique for the Treatment of Choroidal Hemangiomas

“…Previous reports have demonstrated the effectiveness of proton beam irradiation (PBI) for choroidal hemangioma with surgical localization of the tumor using tantalum rings [14,15,16,17]. The physical characteristics of a proton beam – which include minimal scatter, increased dose at the end of the range, and the extremely sharp falloff at the distal end of the beam – make it ideal for localized intraocular irradiation allowing for minimal exposure of surrounding normal intraocular and orbital structures.…”