**3.1 One day session stereotactic radiosurgery for uveal melanoma: our experience**

Stereotactic radiosurgery (SRS) is technically challenging therapeutic irradiating method. SRS complements or supplies (replaces) classic surgical intervention. The purpose of using SRS is single, because high therapeutic irradiation dosage is to involve only an exact specified tumor structure, while the other organs and structures are contemporary protected. We use special hardware equipment of workstation and software. Professional experiences of specialists of various fields (neurosurgeon trained in stereotactic radiosurgery, radiation oncologist, ophthalmologist, radiologist, clinical physicist and registered nurse trained for radiosurgery) are needed.

The surgery is determined by patient preparation before surgery intervention. This consists of processing of health of the patient and whole patients imaging documentation. It is important to analyze the patient's illnesses and the patient's indication by the Indicating Commission (BTB). The Commission consists of the members as a neurosurgeon trained in radiosurgery, radiation oncologists, ophthalmologists, radiologists and clinical physicists. Just after the see the records and imaging of the patients they decides whether to do SRS or not. The Progress Committee selects, on the basis of a recommendation on the suitability of ophthalmic oncological surgery, which evaluates the suitability of conventional surgery, stereotactic radiosurgery, fractional stereotactic radiosurgery, intensity modulated radiotherapy (IMRT) or three-dimensional comfort radiotherapy (3 D-CRT).

Indicated patients for stereotactic radiosurgical intervention are concerned for inpatient care Ophthalmology Department of Faculty of Medicine, Comenius University in Bratislava. The whole hospitalization lasts most often three days. The patient admission includes interview with the patient with detailed information about the course of operation, performance benefits as well as acquaintance with potential acute and late postoperative complications (adverse effects), after the informed consent is signed by the patient.

Patient's affirmation in hospital bed department (clinical care) is carried two days before the surgery. Clinical examination will be done in detail. The documentation patient brought is studied, in case there are some missing examinations they are done and completed by the time of the surgery and a preoperative pharmacotherapy treatment in hospital bed department is placed on. One day before the stereotactic radiosurgery (SRS) patient has to use premedication. Within the preoperative premedication the patient is using the antiedema therapy, which intensity depends on the size, location of the lesion and the presence of edema. The presented therapy continues at the day of surgery and also the following day.

The patient's record must incorporate the age at treatment, volume and size of tumor, the most extreme stature of the tumor estimated by A, B scan ultrasound. The presence and the degree of secondary retinal detachment, and note if there is an extrascleral expansion must be recorded in patients file. Tumor volume, in every

**19**

*Uveal Melanoma*

*DOI: http://dx.doi.org/10.5772/intechopen.95321*

patient straightforwardly after computer CT and MRI assessment is determined as the progression of SRS strategy and is included to the scheme of stereotactic planning. Mechanical fixation to the stereotactic (Leibinger) frame is done before stereotactic irradiation immobilization of the affected eye. Stiches are put under 4 direct extraocular muscles through conjunctiva and through the upper and lower lid. The stereotactic frame is fixed to the head and the stiches are attached to the stereotactic frame on the side of affected eye. The patient undergoes a CT examination with the eye tied to the patient's frame. After fixation and administration of the drug contrast agent, the examination is performed on one-millimeter scans. After completing the CT examination, the patient is transferred to an MRI examination. The patient undergoes an MRI examination with the eye still fixed on a stereotactic frame. After placement in the MRI, a contrast agent is administered. MRI and CT

imaging records are sent to a computer console in the computer room.

and is waiting for exposure in the linear accelerator.

marked as the critical structure.

*3.1.1 Stereotactic planning*

At that point after the CT and MRI examinations patient is transported to the resting room of Department of radiotherapy of St. Elizabeth Oncological Institute

Clinical physicist processes imaging records for the purpose of fusion and subsequent planning of stereotactic radiosurgery irradiation. By the fusion of images obtained from the CT and MRI it is obtained an accurate image and the structurerelationship of operated patient. CT examination does not always perfect morphology image of targeting and risk structures, but it is an accurate and does not distort the displaying structures. MRI can distort displaying targeted and risk structures, particularly in the area of bone structures arises the distortion. Neural structures are showed in three dimensions, which allows a reconstruction and good distinctiveness of targeted and risk neural structures. Planning system communicates only with the CT imaging, in which information is transmitted from other investigating modalities. Clinical physicist makes by the fusion the correction of the treating volume of a focus and risk structures from the MRI records to CT imaging. After imaging the target and risk structures, the neurosurgeon draws the target volumes and risk structures in sections of one millimeter in a CT record and consults them with an ophthalmologist and radiologist. The planning of stereotactic treatment after the fusion of CT and MR is optimized according to the critical structures, which are the lens, the optic nerve on both sides, and chiasma is also

The best plan is after applied for therapy at linear accelerator. Calculation of tumor volume depends on the ROI (region of interest) of the tumor and 3D reconstruction is done. The planned therapeutic dose is 35.0 Gy by 99% of DVH (dose volume histogram). Model LINAC C 600 C/D Varian with 6 MeV X is utilized.

The stereotactic treatment arranging after combination of CT and MRI pictures is streamlined by the basic structures - focal point, optic nerve, and furthermore

The planned therapeutic dose in SRS is 35.0 Gy, TDmin. The dose varies from 35.0 to 38.0 Gy, TDmax 37.0–50.0 Gy to the margin of the lesion. We use PTV (treatment volume planning) at least 95% isodose planning. Doses for critical structures such as the optic nerve and optic disc are less than 8.0 Gy and 10.0 Gy for

The clinical physicist embeds the plan into the verification system after printing the radiation parameters and documentation. At the same day after the planning is finished the patient undergoes irradiation at linear accelerator in the afternoon.

focal point and optic nerve at the contralateral side, chiasm.

the anterior segment of the eye (**Figures 1** and **2**).

#### *Uveal Melanoma DOI: http://dx.doi.org/10.5772/intechopen.95321*

*Melanoma*

**experience**

radiotherapy (3 D-CRT).

informed consent is signed by the patient.

enucleation. Enucleation remains the standard strategy for the board of the biggest melanomas of the choroid and ciliary body. The Collaborative Ocular Melanoma Study (COMS) is randomized clinical trial assessing essential enucleation versus beam radiation done externaly followed by enucleation in the management of patients with choroidal melanomas. The study demonstrated that the two options to be used in same medium sized tumors. COMS studied also treatment of large tumors and found out that combined external radiotherapy followd by enucleation shown that there is no limit in orbital recurrence of the tumor mass [10–13].

**3.1 One day session stereotactic radiosurgery for uveal melanoma: our** 

Stereotactic radiosurgery (SRS) is technically challenging therapeutic irradiating method. SRS complements or supplies (replaces) classic surgical intervention. The purpose of using SRS is single, because high therapeutic irradiation dosage is to involve only an exact specified tumor structure, while the other organs and structures are contemporary protected. We use special hardware equipment of workstation and software. Professional experiences of specialists of various fields (neurosurgeon trained in stereotactic radiosurgery, radiation oncologist, ophthalmologist, radiologist, clinical physicist and registered nurse trained for radiosurgery) are needed. The surgery is determined by patient preparation before surgery intervention. This consists of processing of health of the patient and whole patients imaging documentation. It is important to analyze the patient's illnesses and the patient's indication by the Indicating Commission (BTB). The Commission consists of the members as a neurosurgeon trained in radiosurgery, radiation oncologists, ophthalmologists, radiologists and clinical physicists. Just after the see the records and imaging of the patients they decides whether to do SRS or not. The Progress Committee selects, on the basis of a recommendation on the suitability of ophthalmic oncological surgery, which evaluates the suitability of conventional surgery, stereotactic radiosurgery, fractional stereotactic radiosurgery, intensity modulated radiotherapy (IMRT) or three-dimensional comfort

Indicated patients for stereotactic radiosurgical intervention are concerned for inpatient care Ophthalmology Department of Faculty of Medicine, Comenius University in Bratislava. The whole hospitalization lasts most often three days. The patient admission includes interview with the patient with detailed information about the course of operation, performance benefits as well as acquaintance with potential acute and late postoperative complications (adverse effects), after the

Patient's affirmation in hospital bed department (clinical care) is carried two days before the surgery. Clinical examination will be done in detail. The documentation patient brought is studied, in case there are some missing examinations they are done and completed by the time of the surgery and a preoperative pharmacotherapy treatment in hospital bed department is placed on. One day before the stereotactic radiosurgery (SRS) patient has to use premedication. Within the preoperative premedication the patient is using the antiedema therapy, which intensity depends on the size, location of the lesion and the presence of edema. The presented therapy continues at the day of surgery and also the following day. The patient's record must incorporate the age at treatment, volume and size of tumor, the most extreme stature of the tumor estimated by A, B scan ultrasound. The presence and the degree of secondary retinal detachment, and note if there is an extrascleral expansion must be recorded in patients file. Tumor volume, in every

**18**

patient straightforwardly after computer CT and MRI assessment is determined as the progression of SRS strategy and is included to the scheme of stereotactic planning.

Mechanical fixation to the stereotactic (Leibinger) frame is done before stereotactic irradiation immobilization of the affected eye. Stiches are put under 4 direct extraocular muscles through conjunctiva and through the upper and lower lid. The stereotactic frame is fixed to the head and the stiches are attached to the stereotactic frame on the side of affected eye. The patient undergoes a CT examination with the eye tied to the patient's frame. After fixation and administration of the drug contrast agent, the examination is performed on one-millimeter scans. After completing the CT examination, the patient is transferred to an MRI examination. The patient undergoes an MRI examination with the eye still fixed on a stereotactic frame. After placement in the MRI, a contrast agent is administered. MRI and CT imaging records are sent to a computer console in the computer room.

At that point after the CT and MRI examinations patient is transported to the resting room of Department of radiotherapy of St. Elizabeth Oncological Institute and is waiting for exposure in the linear accelerator.

Clinical physicist processes imaging records for the purpose of fusion and subsequent planning of stereotactic radiosurgery irradiation. By the fusion of images obtained from the CT and MRI it is obtained an accurate image and the structurerelationship of operated patient. CT examination does not always perfect morphology image of targeting and risk structures, but it is an accurate and does not distort the displaying structures. MRI can distort displaying targeted and risk structures, particularly in the area of bone structures arises the distortion. Neural structures are showed in three dimensions, which allows a reconstruction and good distinctiveness of targeted and risk neural structures. Planning system communicates only with the CT imaging, in which information is transmitted from other investigating modalities. Clinical physicist makes by the fusion the correction of the treating volume of a focus and risk structures from the MRI records to CT imaging.

After imaging the target and risk structures, the neurosurgeon draws the target volumes and risk structures in sections of one millimeter in a CT record and consults them with an ophthalmologist and radiologist. The planning of stereotactic treatment after the fusion of CT and MR is optimized according to the critical structures, which are the lens, the optic nerve on both sides, and chiasma is also marked as the critical structure.

The best plan is after applied for therapy at linear accelerator. Calculation of tumor volume depends on the ROI (region of interest) of the tumor and 3D reconstruction is done. The planned therapeutic dose is 35.0 Gy by 99% of DVH (dose volume histogram). Model LINAC C 600 C/D Varian with 6 MeV X is utilized.

#### *3.1.1 Stereotactic planning*

The stereotactic treatment arranging after combination of CT and MRI pictures is streamlined by the basic structures - focal point, optic nerve, and furthermore focal point and optic nerve at the contralateral side, chiasm.

The planned therapeutic dose in SRS is 35.0 Gy, TDmin. The dose varies from 35.0 to 38.0 Gy, TDmax 37.0–50.0 Gy to the margin of the lesion. We use PTV (treatment volume planning) at least 95% isodose planning. Doses for critical structures such as the optic nerve and optic disc are less than 8.0 Gy and 10.0 Gy for the anterior segment of the eye (**Figures 1** and **2**).

The clinical physicist embeds the plan into the verification system after printing the radiation parameters and documentation. At the same day after the planning is finished the patient undergoes irradiation at linear accelerator in the afternoon.

#### **Figure 1.**

*Stereotactic planning scheme for patient with uveal melanoma on linear accelerator (TD – 35.0 Gy) – Part a. origin: Dept. of stereotactic radiosurgery, Bratislava.*

#### **Figure 2.**

*Stereotactic planning scheme for patient with uveal melanoma on linear accelerator (TD – 35.0 Gy) – Part B. origin: Dept. of stereotactic radiosurgery, Bratislava.*

Mechanical fixation to the stereotactic frame ensures that the head while the examination and treatment is in the same, right position. Along with the merger of images from CT and MRI is guaranteed the accuracy of the method in the order of tenths of a millimeter.

When the exposure id completed the patient is unfixed from the operating table and moved into the operating room. According to volume and collimators the whole procedure lasts from 15 to 50 minutes.

In the case of application of stereotactic radiosurgery using micro-multileaf collimator makes clinical physicist verification plan using the verification phantom. He inserts the irradiation plan of patient into verification system of linear accelerator and verifies the accuracy of irradiation plan applications into verification phantom by irradiation of verification phantom by the dosimetric system.

**21**

*Uveal Melanoma*

after SRS.

after the treatment.

melanocytomas.

extrascleral spread.

post-treatment.

a case-by-case basis.

noma is still in discussion.

*DOI: http://dx.doi.org/10.5772/intechopen.95321*

*3.1.2 Stereotactic radiosurgery for uveal melanoma: Our results*

noma by one-day session of LINAC stereotactic radiosurgery.

irradiation (SRS) in interval 1 and 2 years after the treatment.

maximal elevation, middle 4–8 mm, and large over 8 mm.

*3.1.3 Enucleation versus stereotactic radiosurgery: Our results*

patients with posterior uveal melanoma.

Treatment of uveal melanoma in Slovakia is performed on direct quickening agent LINAC. One-fraction LINAC radiotherapy/radiosurgery is an unusual approach to treatment of choroidal melanoma. Hypofractionation with a broad shoulder in linear-quadratic model for radioresistant tumors like choroidal mela-

We evaluated in our study local failure which leads into enucleation as an end point in patients treated by SRS with long-term follow-up having accrued at the time of analysis. We evaluate in our study the treatment of posterior uveal mela-

The first goal of our study was to evaluate treatment BCVA decline in patients who has posterior uveal melanoma treated with SRS in 6 months interval 24 months

The second goal was to find out whether the group of patients with better initial visual acuity on the beginning of treatment would have also a better chance to preserve vision. The observed after-treatment decline in BCVA was 24 months interval

The third goal was observation of the tumor regression by the maximum elevation measurement using B-scan ultrasound in the group of patients with single

For patients treated by SRS in the period 2001–2008 was a retrospective analysis

Each patient record must have details such as the age at treatment, tumor size, tumor volume, the maximum height of the tumor by A, B scan ultrasound, the presence and the extent of secondary retinal detachment, and if there are signs of

The tumors were divided into 3 groups as follows: small up to 4 or 5 mm of

In the group of one stereotactic irradiation, an increase in the tumor was observed in a 6-month interval by ultrasound with a B-scan ophthalmologist. We compared tumor regression by measuring maximal elevation using B-scan ultrasound in a group of 25 patients with single irradiation (SRS) at 12 and 24 months

We analyzed the treatment outcome and possible survival difference between radical surgical treatment (primary enucleation) and stereotactic radiosurgery (SRS) at the Department of Ophthalmology, Comenius University in Bratislava, in

Patients treated for uveal melanoma in posterior during the period 2001–2008 are analyzed in the study. The goal of the study was to compare the relapse-free survival in the cohort of patients initially treated by SRS or they primary underwent enucleation. Together we included 84 patients. Treatment was determined on

was undertaken. At the Department of Ophthalmology, Comenius University in Bratislava we reviewed 84 patients records with choroidal melanoma or with ciliary body melanoma treated in this period. 44 patients underwent primary enucleation (52.4%) out of 84 patients and 40 patients underwent SRS as an initial treatment (47.6%). The diagnosis was established on the basic of ophthalmological examination, ultrasound, CT or MRI examination. Excluded from analyzed cohort were metastatic intraocular tumors, juxtapapillary localized tumors and

*Melanoma*

**Figure 1.**

**20**

tenths of a millimeter.

**Figure 2.**

procedure lasts from 15 to 50 minutes.

*origin: Dept. of stereotactic radiosurgery, Bratislava.*

*origin: Dept. of stereotactic radiosurgery, Bratislava.*

Mechanical fixation to the stereotactic frame ensures that the head while the examination and treatment is in the same, right position. Along with the merger of images from CT and MRI is guaranteed the accuracy of the method in the order of

*Stereotactic planning scheme for patient with uveal melanoma on linear accelerator (TD – 35.0 Gy) – Part B.* 

*Stereotactic planning scheme for patient with uveal melanoma on linear accelerator (TD – 35.0 Gy) – Part a.* 

When the exposure id completed the patient is unfixed from the operating table and moved into the operating room. According to volume and collimators the whole

In the case of application of stereotactic radiosurgery using micro-multileaf collimator makes clinical physicist verification plan using the verification phantom. He inserts the irradiation plan of patient into verification system of linear accelerator and verifies the accuracy of irradiation plan applications into verification phantom

by irradiation of verification phantom by the dosimetric system.
