Elsevier

Survey of Ophthalmology

Volume 54, Issue 5, September–October 2009, Pages 545-568
Survey of Ophthalmology

Major Review
Radiation Therapy for Orbital Tumors: Concepts, Current Use, and Ophthalmic Radiation Side Effects

https://doi.org/10.1016/j.survophthal.2009.06.004Get rights and content

Abstract

Radiation therapy is widely used for the treatment of orbital tumors and inflammatory disease. Both external beam teletherapy and implant brachytherapy radiation techniques are employed. External beam radiation therapy is the most common. It involves directing an external radiation source towards the eye, sinuses, and orbit. Whereas most patients are treated with linear accelerator–derived external beam radiation therapy, proton, neutron stereotactic radiosurgery, gamma knife, and intensity-modulated radiation therapy have become more available in developed countries. Radiation can be used alone or together with surgery or chemotherapy. Implant radiation therapy (brachytherapy) is also used to treat orbital tumors. Brachytherapy involves surgical placement of radiation sources within the tumor or targeted volume. Characteristically conformal, brachytherapy increases the dose within the target while maximally decreasing exposure of normal tissues. Orbital brachytherapy can be used to boost the dose to the target volume prior to orbital external beam radiation therapy. Herein, I explore the unique challenges associated with irradiation of the orbit, basic radiobiology, doses, indications, and results of treatment. The tolerances of normal ocular and orbital tissues are reported. This review of the literature offers a unique perspective, synthesizing the world's experience on the use of orbital radiation therapy.

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,

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    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.”

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