Treatment planning considerations for 125I eye plaque brachytherapy.

Effective cancer brachytherapy requires a treatment plan that delivers high-dose to tumor, while minimizing the dose to critical normal tissues. Therefore, an accurate knowledge of the sources and magnitude of the techniques is essential for producing robust and well optimized-plans. The purpose of this technical note is to establish general procedures and strategies for optimization and customization of the plaques loaded with radioactive seeds, particularly focusing on the definition of useful tactics to limit high doses to organs at risk and adapt the treatment time to the necessity of institution.

Episcleral brachytherapy as an effective alternative in vasoproliferative tumors.

The aim of this study is to assess the results of episcleral brachytherapy as treatment of retinal vasoproliferative tumors (RVTs) in a referral Intraocular Tumors Unit (ITU). A retrospective review of all patients diagnosed with vasoproliferative tumors of the retina and treated with episcleral brachytherapy in the ITU, University Hospital of Valladolid between 2009 and 2015 was done. Five patients accomplished the inclusion criteria. All of them presented associated exudation and secondary retinal detachments (RD). Four patients had received prior treatments. Decreased tumor size and exudation regression was found in all cases after treatment. Visual acuity remained stable or increased in all patients. No recurrences have been found after twelve-months follow up. The results of the present study suggest that episcleral brachytherapy is an efficient and safe option in the management of vasoproliferative tumors, especially when large tumor or extensive subretinal fluid is present. In these cases episcleral brachytherapy could be considered as a first line treatment.

Radiobiological doses, tumor, and treatment features influence on local control, enucleation rates, and survival after epiescleral brachytherapy. A 20-year retrospective analysis from a single-institution: part I.

PURPOSE: To assess influence of the radiobiological doses, tumor, and treatment features on local control, enucleation rates, overall and disease-specific survival rates after brachytherapy for posterior uveal melanoma. MATERIAL AND METHODS: Local control, enucleation, overall and disease-specific survival rates were evaluated on the base of 243 patients from 1996 through 2016, using plaques loaded with iodine sources. Clinical and radiotherapy data were extracted from a dedicated prospective database. Biologically effective dose (BED) was included in survival analysis using Kaplan-Meier and Cox regressions. The 3-, 5-, 10-, and 15-year relative survival rates were estimated, and univariate/multivariate regression models were constructed for predictive factors of each item. Hazard ratio (HR) and confidence interval at 95% (CI) were determined. RESULTS: The median follow-up was 73.9 months (range, 3-202 months). Cumulative probabilities of survival by Kaplan-Meier analysis at 3, 5, 10 and 15 years were respectively: 96%, 94%, 93%, and 87%, for local control; 93%, 88%, 81%, and 73% for globe preservation; 98%, 93%, 84%, and 73% for overall survival, and 98%, 96%, 92%, and 87% for disease-specific survival. By multivariate analysis, we concluded variables as significant: for local control failure - the longest basal diameter and the juxtapapillary location; for globe preservation failure - the longest basal dimension, the mushroom shape, the location in ciliary body, and the dose to the foveola; for disease-specific survival - the longest basal dimension. Some radiobiological doses were significant in univariate models but not in multivariate ones for the items studied. CONCLUSIONS: The results show as predictive factors of local control, enucleation, and disease-specific survival rates those related with the features of the tumor, specifically the longest basal dimension. There is no clear relation between radiobiological doses or treatment parameters in patients after brachytherapy.

Radiobiological doses, tumor, and treatment features influence on outcomes after epiescleral brachytherapy. A 20-year retrospective analysis from a single-institution: part II.

PURPOSE: To assess the influence of the radiobiological doses, tumor, and treatment features on retinopathy, cataracts, retinal detachment, optic neuropathy, vitreous hemorrhage, and neovascular glaucoma at the authors' institution after brachytherapy for posterior uveal melanoma. MATERIAL AND METHODS: Medical records of 243 eyes with uveal melanoma, treated by iodine brachytherapy between 1996 and 2016 at a single center were analyzed. Clinical and radiotherapy data were extracted from a dedicated database. Biologically effective dose (BED) was included in survival analysis performed using Kaplan-Meier and Cox regressions. Relative survival rates were estimated, and univariate/multivariate regression models were constructed for predictive factors of each item. Hazard ratio and confidence interval at 95% were determined. Variables statistically significant were analyzed and compared by log-rank tests. RESULTS: The median follow-up was 73.9 months (range, 3-202 months). Cumulative probabilities of survival by Kaplan-Meier analysis at 3 and 5 years, respectively, were: 59% and 48% for retinopathy; 71% and 55% for cataracts; 63% and 57% for retinal detachment; 88% and 79% for optic neuropathy; 87% and 83% for vitreous hemorrhage; 92% and 89% for neovascular glaucoma, respectively. Using multivariate analysis, statistically significant risk factors were: age, tumor apical height, dose to foveola, and location of anterior border for retinopathy; age, dose to lens, type of plaque, and tumor shape, for cataracts; age, tumor apical height, and size of the plaque for retinal detachment; age, plaque shape, longest basal dimension, and BED to optic nerve for optic neuropathy; age, tumor apical height, and tumor shape for vitreous hemorrhage; tumor apical height and BED to foveola for neovascular glaucoma. CONCLUSIONS: Tumor factors in addition to radiation treatment may contribute to secondary effects. Enhanced clinical optimization should evaluate radiobiological doses delivered to the tumor volume and surrounding normal ocular structures.

Visual outcome after posterior uveal melanoma episcleral brachytherapy including radiobiological doses.

PURPOSE: To assess the long-term influence of radiobiological doses in the evolution of visual acuity (VA) in patients with uveal melanoma treated by episcleral brachytherapy. MATERIAL AND METHODS: Visual acuity was evaluated prospectively from a case series of 243 patients in 2016 treated with 125I. Data analysis was applied to trend VA outcome and find the accurate best-fit line. Biologically effective dose (BED) was included in survival analysis with the use of Kaplan-Meier and Cox regressions. Hazard ratio (HR) and confidence interval at 95% (CI) were determined. Variables statistically significant were analyzed and compared by log-rank tests. RESULTS: The median follow-up was 74.2 months (range, 3-223). Exponential regression shows a 25% reduction and 50% in visual acuity score (VAS) scale for 5 and 27.8 months, respectively. Cumulative probabilities of survival analysis were 57%, 42%, 27%, and 23% at 3, 5, 10, and 15 years, respectively. Multivariable analysis found tumor height (HR = 1.18, 95% CI: 1.07-1.29), applicator size (HR = 1.22, 95% CI: 1.08-1.36), juxtapapillary localization (HR = 1.70, 95% CI: 1.01-2.84), and dose to foveola (HR = 1.01, 95% CI: 1.00-1.01) significantly associated with VA loss. Log-rank tests were significant for all those variables. BED has a strong influence in univariate model, but not statistically significant in the multivariate one. CONCLUSIONS: Visual acuity changes can be modeled by an exponential function for the first 5 years after treatment. No relation between VA loss and BED has been found; nevertheless, apical height, plaque size, juxtapapillary localization, and dose to fovea were found as statistical significant variables.

Infiltrative Intraocular Conjunctival Squamous Cell Carcinoma after Local Resection and Brachytherapy: Clinical and Pathological Findings.

A pseudophakic 70-year-old man presented to the clinic with a slow-growing conjunctival mass in the left eye. He was diagnosed with a conjunctival exophytic lesion suspicious of invasive conjunctival squamous cell carcinoma (CSCC). Excisional biopsy showed a well-differentiated CSCC with positive margins and the patient underwent adjuvant brachytherapy. Six weeks later, examination of the anterior segment revealed cells in the anterior chamber and a neurotrophic corneal ulcer with corneal perforation. Considering the high suspicion of intraocular invasion of CSCC, the left eye was enucleated. Histopathologic findings showed scarring of the ciliary body with fibrosis temporally. Nasally, the sclera showed a lobular infiltration of well-differentiated squamous carcinoma. The central cornea exhibited a large ulcer with perforation and infiltrating squamous cells adhering to the posterior surface. To our knowledge, this is the first documented case of an intraocular diffuse recurrence of CSCC after resection and adjuvant brachytherapy, with clinicopathologic correlation of radiation effects on the ocular tissues.

Pattern of Local Recurrence After I-125 Episcleral Brachytherapy for Uveal Melanoma in a Spanish Referral Ocular Oncology Unit.

PURPOSE: To describe the time, frequency, and clinical characteristics of treatment failure after I-125 brachytherapy in patients with uveal melanoma treated and followed in a Spanish referral ocular oncology unit. DESIGN: Prospective, consecutive, interventional case series. METHODS: Patients diagnosed with uveal melanoma from 1995 to 2016 and treated with episcleral brachytherapy were included. Demographic data collection, ophthalmic evaluation, ultrasound scan, and systemic studies were performed at baseline, every 6 months thereafter for 5 years, and subsequently at annual intervals. Recurrence was defined as presence of tumor growth after treatment. Baseline analysis was performed by descriptive methods and survival by Kaplan-Meier curves. RESULTS: From 732 patients diagnosed with uveal melanoma, 311 were treated with brachytherapy. In the follow-up (mean 79 months, standard deviation = 55), 16 local tumor recurrences (5.1%) were detected. All relapsing patients had choroidal tumors and 15 presented with visual symptoms. All patients were treated with I-125 brachytherapy, and 2 received associated transpupillary thermotherapy. All the eyes were enucleated after recurrence. Kaplan-Meier analysis showed a mean time of recurrence of 3.7 years (standard deviation = 2.94 years, ranging from 1 to 12 years). Three patients had metastasis in the follow-up. Kaplan-Meier analysis showed worse survival for patients with recurrence. CONCLUSION: Local treatment failure was a relatively infrequent event after I-125 brachytherapy in our series. Recurrences appear not only early but also late in the follow-up. They do not have a distinctive clinical pattern and are associated with poorer survival.

Episcleral brachytherapy for uveal melanoma: analysis of 136 cases.

PURPOSE: To assess the results of I-125 episcleral brachytherapy (EB) in uveal melanoma: tumour control, visual acuity (VA), eye preservation and survival. PATIENTS: Prospective and consecutive study of patients with a diagnosis of uveal melanoma at the Ocular Oncology Unit in the Valladolid University Teaching Hospital treated with EB between September 1997 and June 2008. Ocular examination and extraocular and systemic extension data were registered in a database at the time of the diagnosis and during the follow-up. RESULTS: Among a total of 310 patients diagnosed between September 1997 and June 2008, 136 were treated with EB (mean age, 58.3). Mean follow-up was 55.3 months. As for tumour type, 66.9% were nodular and 39% mushroom shaped. With respect to size, 80.9% were medium, 7.4% small and 11.8% large. After 4.6 years of follow-up, tumours were controlled in 97.1%, with a 55.1% reduction in mean height; only 2.9% of patients showed recurrence. VA was maintained in 16.2% of patients and 17.6% showed an increase; 33% had retinopathy and 14.6% optic neuropathy. Only 5.1% of patients underwent enucleation due to complications and there has been 1 melanoma-related death to date. CONCLUSIONS: I-125 EB is effective in tumour control, allowing preservation of the eye and useful visual function for the majority of patients.

A pilot study of satisfaction in oncology nursing care: an indirect predictor of quality of care.

PURPOSE: Although "satisfaction" is not easy to define, excellence in health care is impossible without professional/patient satisfaction, so this paper aims to report on a pilot study designed in order to evaluate the degree of nursing staff satisfaction with the implementation of measures to improve quality of care. DESIGN/METHODOLOGY/APPROACH: The project consisted of several phases: writing protocols of care; training of nursing staff in their management; and a cross-sectional study to evaluate nursing staff satisfaction with them. The design of the survey consisted of a 16-item Likert scale, which had to be auto filled. A factorial analysis to simplify and validate the tools was used, using statistical analyses with SPSS software 8.0. PRACTICAL IMPLICATIONS: The results are applicable to young small oncological units with high degree of variability in patient care. The study showed that nursing staff satisfaction with new improvement measures taken improves safety and finally quality of care. FINDINGS: The study obtained four dimensions (D) explaining 100 percent of variance. Each dimension with several items: D1: "Nursing job quality" explaining 48.4 percent of variance; D2: "Satisfaction with the knowledge"; D3: "Nursing job feelings/perceptions"; D4: "Nursing communication with doctors/patients". It provided a direct point of view of each nurse, knowledge about problems encountered daily and demonstration of how a simple/convenient method is useful to engage the staff in decision-making-process and implementation of new strategies or to promote the integration of basic aspects of health management in daily clinical practice. ORIGINALITY/VALUE: This is the first study evaluating nursing staff satisfaction with new improvement measures taken in a small medical unit, aiming at quality of care benefits. Very promising results were obtained although the sample size was small.

Life after breast cancer: dealing with lymphoedema.

BACKGROUND: In recent years, breast cancer (BC) mortality rates have declined, reflecting advances in early detection. Prevention and management of treatment sequelae that could impair function or quality of life have increased in relevance. Lymphoedema after BC treatment is one of these sequelae. It is caused by an acquired interruption or damage to the axillary lymphatic system and it is characterized by an abnormal accumulation of fluids and other substances in the tissue. PURPOSE: We observed a group of patients with incidents of BC aiming to estimate the lymphoedema incidence, degree, time course, symptoms and treatment they received. METHODS AND RESULTS: We evaluated 127 women. Median age was 58 years. 66% were postmenopausal. The median number of axillary nodes was 9. Over the first five years of follow-up we were informed about hand/arm swelling, thickness or tiredness by 37% of this group. The median of axillary nodes affected by metastatic cells in our patients with lymphoedema was 6. The symptoms they referred to us as the most relevant were heaviness (33%), tiredness (27%), jewelry or clothing too tight (25%), swelling and indentations (9%) and difficulty writing (6%). Several of them had psychological problems. CONCLUSION: We know of the relevance of lymphoedema in BC patients but its natural history and most effective therapies are poorly understood. Self-reported symptoms are relevant to promptly start therapy.

Pilot study of a clinical pathway implementation in rectal cancer.

BACKGROUND: Rectal cancer is a highly prevalent disease which needs a multidisciplinary approach to be treated. The absence of specific protocols implies a significant and unjustifiable variability among the different professionals involved in this disease. The purpose is to develop a clinical pathway based on the analysis process and aims to reduce this variability and to reduce unnecessary costs. METHODS: We created a multidisciplinary team with contributors from every clinical area involved in the diagnosis and treatment in this disease. We held periodic meetings to agree on a protocol based on the best available clinical practice guidelines. Once we had agreed on the protocol, we implemented its use as a standard in our institution. Every patient older than 18 years who was diagnosed with rectal cancer was considered a candidate to be treated via the pathway. RESULTS: We evaluated 48 patients during the course of this study. Every parameter measured was improved after the implementation of the pathway, except the proportion of patients with 12 nodes or more analysed. The perception that our patients had about this project was very good. CONCLUSIONS: Clinical pathways are needed to improve the quality of health care. This kind of project helps reduce hospital costs and optimizes the use of limited resources. On the other hand, unexplained variability is also reduced, with consequent benefits for the patients.

Drug extravasation: a dreaded complication.

A 62-year-old man diagnosed with a stage I lung adenocarcinoma was treated by an upper right lobectomy. Eighteen months later an elevation of carcinoembryoinc antigen (CEA) was detected, and CT tomography revealed a stage IV disease. Chemotherapy including cisplatin (Platinol) and docetaxel (Taxotere) was administered. He presented 12 days after receiving an intravenous infusion because he noticed a burning sensation, erythema and blisters at the site of the last infusion and proximal to that area. On physical examination he had a 9×4.5 cm swollen area of erythema and multiple blisters. The diagnosis of delayed and distant docetaxel extravasation was made. The treatment consisted of normal saline washes, topical hydrocortisone and antibiotic-based ointment which produced relief of the symptoms. This reaction resolved over the next 6 weeks, leaving two areas of brownish pigmentation of the skin as the only sequelae.