Major ReviewRadiation Therapy for Orbital Tumors: Concepts, Current Use, and Ophthalmic Radiation Side Effects
Introduction
Orbital anatomy and ocular radiosensitivity provide unique challenges for radiation therapy. By definition, orbital tumors occur within the space between the eyeball and bony orbital walls. This includes tumors that extend from the eye into the orbit, as well as those from the adjacent adnexae, sinuses, bone, and brain.
Each radiation delivery system (teletherapy or brachytherapy) has unique characteristics that allow for distinctive dose distributions within the orbit. In order to better understand the differences between radiation modalities, I review their intrinsic characteristics and the reasons why each is employed.
Side effects have been reported after radiation therapy. There exists a spectrum of radiation tolerance among normal ocular tissues. For example, whereas orbital bones, muscle, and fat can tolerate relatively high doses; the lens, eyelashes, retina, and lacrimal system are more radiosensitive.217 Side effects such as dry eye, eyelash loss, cataract, neovascular glaucoma, radiation retinopathy, and optic neuropathy are all potential local complications of orbital irradiation. 8, 58, 162, 210, 222 Therefore, although tumor control is the primary goal, treatment plans (dose volumes) are shaped to avoid the retina, lacrimal system, and natural lens (to decrease side effects). Lastly, there are oncogenic risks associated with ionizing radiation.94, 95
Radiation plays an indispensible role in the treatment of benign and malignant orbital disease. This is because the clinical benefits of improving survival and preserving vision clearly outweigh the risks. This study reviews how radiotherapy plays an integral role in the treatment of benign and malignant orbital tumors.
Section snippets
External beam radiation therapy
External beam radiation therapy (EBRT) is currently delivered utilizing photons (gamma rays or X ray) or particles (protons or neutrons), with linear accelerators (LINACs) doing the bulk of the work.27, 32, 104, 119, 152, 168, 169, 184, 196 The LINAC creates energetic photons by using high-frequency electromagnetic waves to accelerate electrons through a microwave accelerator structure. This relatively low-energy electron beam offers limited penetration that can be used to treat superficial
Irradiation of Specific Orbital Tumors
Radiation currently plays an important role as both primary treatment and adjuvant therapy, and for palliation of orbital tumors. Different doses are used depending on the clinical situation, radiation source, and desired result. The following reviews the published experience with radiation for adnexal tumors and intraocular malignancies with orbital extension as well as primary orbital tumors (Table 1).
Metastasis
The most common intraocular cancer, uveal metastases, is typically treated with EBRT.66, 150, 208, 258, 266 Mostly derived from breast cancer in women and from lung cancer in men, other primary sites include the prostate, colon, kidney, thyroid, and skin.82, 199 Most ocular metastases occur towards the end of life, are asymptomatic, undiagnosed, and are left untreated.208 However, in clinical practice, most patients present when they develop visual symptoms related to involvement of the macular
Side Effects of Orbital Radiation Therapy
It was not long after the discovery of the X ray that Chalupecky published his study on its effect on the eye.36 The eye was noted to be relatively radiation sensitive by Birch-Hirshfeld and Amman, who reported the first radiation-induced cataracts [Amman E. Zur Wirkung der Roentgenstrahlen auf das menschliche auge. Korrespondez-Blatt fur Schweizer Artze 15; 1906].24, 217 In 1970, Macfaul and Bedford described a spectrum of ocular complications related to therapeutic radiation (primarily, but
Summary
Radiation therapy continues to play an essential role in the management of benign and malignant orbital tumors. We have experience with its use for primary orbital, sinus, intraocular, and adnexal tumors with orbital extension. New and exciting computerized radiation modalities are continually introduced to clinical medicine. Therefore, I expect we will continue to use progressively more conformal external beam and brachytherapy techniques to improve local tumor control and decrease
Method of Literature Search
The references in our review were obtained using the following databases: National Library of Medicine's PubMed and MEDLINE. References within these articles were also reviewed. The results of this review include published works from 1897 to 2008. There is an “In press” reference to the 7th Edition AJCC-UICC Ophthalmic Oncology Nomenclature, scheduled to be published in 2009. The keywords used were eye, orbit, eyelid, lens, sclera, cornea, iris, retina, optic nerve, macula, pituitary,
References (269)
- et al.
Second nonocular tumors in retinoblastoma survivors. Are they radiation-induced?
Ophthalmology
(1984) - et al.
Implant brachytherapy: a novel treatment for recurrent orbital rhabdomyosarcoma
J Aapos
(1997) - et al.
Fractionated stereotactic radiation therapy for extracranial head and neck tumors
Int J Radiat Oncol Biol Phys
(2000) - et al.
Tumor metastasis to the eye. I. Incidence in 213 adult patients with generalized malignancy
Am J Ophthalmol
(1967) - et al.
Tumor metastasis to the eye. II. Clinical study in infants and children
Am J Ophthalmol
(1967) - et al.
Radiation therapy for skin cancer near the eye: kilovoltage x-rays versus electrons
Int J Radiat Oncol Biol Phys
(1992) - et al.
Radiotherapy of lymphoid diseases of the orbit
Int J Radiat Oncol Biol Phys
(1985) - et al.
Treatment and prognosis in a series of primary extranodal lymphomas of the ocular adnexa
Ann Oncol
(1998) - et al.
125I embedded in an orbital prosthesis for retreatment of recurrent retinoblastoma
Med Dosim
(1993) - et al.
Curative radiotherapy for primary orbital lymphoma
Int J Radiat Oncol Biol Phys
(2002)
Radiotherapy in the management of orbital lymphoma
Int J Radiat Oncol Biol Phys
Short term toxicity profile for 32 sinonasal cancer patients treated with IMRT. Can we avoid dry eye syndrome?
Radiother Oncol
Optic pathway tumors
Neurol Clin
Role of propranalol in the therapeutic strategy of infantile laryngotracheal hemangioma
Int J Pediatr Otorhinolarmngol
Treatment of orbital pseudotumor (idiopathic orbital inflammation) by radiation therapy
Int J Radiat Oncol Biol Phys
Treatment of locally advanced adenoid cystic carcinoma of the head and neck with neutron radiotherapy
Int J Radiat Oncol Biol Phys
Precision radiation therapy for optic nerve sheath meningiomas
Int J Radiat Oncol Biol Phys
A retrospective analysis of different modalities for treatment of primary orbital non-Hodgkin's lymphomas
Radiother Oncol
Anti-VEGF bevacizumab (Avastin) for radiation optic neuropathy
Am J Ophthalmol
Plaque radiation therapy for malignant melanoma of the iris and ciliary body
Am J Ophthalmol
Radiation retinopathy is treatable with anti-vascular endothelial growth factor bevacizumab (Avastin)
Int J Radiat Oncol Biol Phys
Radiation therapy for choroidal melanoma
Surv Ophthalmol
Risk factors for metastasis in retinoblastoma
Surv Ophthalmol
Choroidal metastasis from adenoid cystic carcinoma of the lung
Am J Ophthalmol
Visual recovery after radiation therapy for bilateral subfoveal acute myelogenous leukemia (AML)
Am J Ophthalmol
Adult wilms' tumor metastatic to the choroid of the eye
Ophthalmology
Radiation late effects in children treated for orbital rhabdomyosarcoma
Radiother Oncol
Proton radiation therapy (PRT) for pediatric optic pathway gliomas: comparison with 3D planned conventional photons and a standard photon technique
Int J Radiat Oncol Biol Phys
The influence of positive margins and nerve invasion in adenoid cystic carcinoma of the head and neck treated with surgery and radiation
Int J Radiat Oncol Biol Phys
Tumors metastatic to the orbit: a changing picture
Surv Ophthalmol
Radiation therapy of optico-hypothalamic gliomas (OHG): radiographic response, vision and late toxicity
Radiother Oncol
Radiation maculopathy after proton beam irradiation for choroidal melanoma
Ophthalmology
Radiation and chemotherapy of parameningeal rhabdomyosarcoma involving the orbit
Ophthalmology
Capillary hemangioma (infantile periocular hemangioma)
Surv Ophthalmol
Simultaneous bilateral radiation for advanced bilateral retinoblastoma
Arch Ophthalmol
The risk of radiation-induced carcinogenesis after external beam radiotherapy of Graves' orbitopathy
Ophthalmic Res
Acute and late side effects of radiotherapy for ocular disease: an overview
Front Radiat Ther Oncol
Ocular metastases from breast carcinoma: a multicentric retrospective study
Oncol Rep
Fractionated stereotactic radiotherapy for the treatment of optic nerve sheath meningiomas: preliminary observations of 33 optic nerves in 30 patients with historical comparison to observation with or without prior surgery
Neurosurgery
Ocular and orbital complications following the treatment of retinoblastoma
Eur J Ophthalmol
Radiation retinopathy: clinical, histopathological, ultrastructural and experimental correlations
Eye
[Comparative study of beta irradiation (106Ru/106Rh) and gamma irradiation (125I) on the rabbit eye]
Ophthalmologica
Photodynamic therapy for maculopathy due to radiation retinopathy
Eye
Orbital radiotherapy for Graves' ophthalmopathy
Thyroid
The corneal and conjunctival complications following radiotherapy
Proc R Soc Med
Orbital radiotherapy for thyroid-related orbitopathy
Curr Opin Ophthalmol
High risk of subsequent neoplasms continues with extended follow-up of childhood Hodgkin's disease: report from the Late Effects Study Group
J Clin Oncol
Die wirkung der roentgen und radiumstrahlen auf das auge
Graefes Arch Clin Exp Ophthalmol
Indolent stage IE non-Hodgkin's lymphoma of the orbit: results after primary radiotherapy
Ophthalmologica
The incidence of ocular metastatic carcinoma
Arch Ophthalmol
Cited by (118)
Metastatic squamous cell carcinoma masquerading as acute retinal necrosis
2023, American Journal of Ophthalmology Case ReportsOptic disc cupping after circumpapillary Pd-103 slotted plaque radiation therapy
2023, Canadian Journal of OphthalmologyApplications of Plaque Brachytherapy in Posterior Segment Tumors: A Clinical Review
2021, Advances in Ophthalmology and OptometryOccult anterior uveal melanomas presenting as extrascleral extension
2023, British Journal of OphthalmologyChoroidal metastasis: Radiation and bevacizumab at presentation
2023, Indian Journal of OphthalmologyEarly anti-VEGF treatment for radiation maculopathy and optic neuropathy: lessons learned
2023, Eye (Basingstoke)
The work was supported by The EyeCare Foundation, Inc, New York, New York, USA. The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article. On June 30th, 2009, Dr. Finger was awarded US Patent Number 7,553,486 titled, “Anti-VEGF treatment for radiation-induced vasculopathy.”