Proton beam irradiation of choroidal hemangiomas

doi:10.1016/S0002-9394(98)00150-0

American Journal of Ophthalmology

Volume 126, Issue 2, August 1998, Pages 261-268

https://doi.org/10.1016/S0002-9394(98)00150-0 Get rights and content

Abstract

PURPOSE: To present a large series of choroidal hemangiomas treated with proton beam irradiation and to describe the treatment outcomes.

METHODS: We treated 54 eyes of 53 patients with choroidal hemangioma. The lesions consisted of 48 circumscribed hemangiomas and six diffuse hemangiomas in patients with Sturge-Weber syndrome. The total applied dose was 27.3 Gy in four eyes, 22.7 Gy in three eyes, and 16.4 Gy to 18.2 Gy in 47 eyes.

RESULTS: The retina reattached within six months after treatment in all 54 eyes and no recurrence of the secondary retinal detachment occurred within the follow-up period of 6 months to 9 years. Tumors treated with the higher doses regressed faster than tumors treated with the lower doses, but radiation-induced complications of the optic nerve appeared in all four eyes treated with a total dose of 27.3 Gy. Of 31 eyes treated with 16.4 to 18.2 Gy and followed for more than 1 year, 22 had an improvement in their visual acuity, and nine retained the same visual acuity. At the last follow-up examination, the best-corrected visual acuity was 20/20 or better in nine eyes, 20/40 to 20/25 in 13 eyes, 20/100 to 20/50 in six eyes, and 20/200 or less in three eyes.

CONCLUSIONS: Proton beam irradiation of choroidal hemangiomas appears to be a valid therapeutic alternative. A total proton dose ranging from 16.4 to 18.2 Gy applied in four daily fractions seems adequate to ensure local control of both tumor and secondary retinal detachment.

Section snippets

Patients and methods

Our series is composed of 54 eyes of 53 patients with choroidal hemangioma treated with proton beam irradiation between 1988 and 1997. The hemangiomas were isolated in 48 patients (33 men and 15 women; age range, 29 to 71 years; mean age, 52.3 years). In five patients, the hemangioma was related to Sturge-Weber syndrome (one male and four females; age range, 10 to 33 years; mean age, 19.8 years). One of these female patients presented with bilateral hemangiomas and both eyes were treated with

Results

For the four eyes treated with a total dose of 27.3 Gy, the follow-up time was 8 to 9 years. Three of these eyes had isolated hemangiomas, and one had hemangioma related to Sturge-Weber syndrome. All of these tumors were in contact with the optic disk, which received a full dose of irradiation. The retina reattached within 6 months after treatment in all four eyes. All tumors regressed completely, and a flat scar with a thickness of 0.8 to 1.2 mm remained at 6 months in one eye and for over a

Discussion

Various irradiation techniques 4, 12, 13, 14, 15, 16, 17 have been used for the treatment of choroidal hemangiomas. The aim of this study was to investigate the efficiency of proton beam irradiation. This technique allows delivery of a homogeneous dose to the well-defined target without any irradiation of healthy tissue located more than 2 mm outside the lateral and the distal margins of the target. It thus differs significantly from the x-ray irradiation technique, which applies a full dose to

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Circumscribed choroidal hemangioma: Comparative efficacy of transpupillary thermotherapy, indocyanine green-enhanced transpupillary thermotherapy, and photodynamic therapy and analysis of baseline clinical features effecting treatment outcomes
2021, Photodiagnosis and Photodynamic Therapy
To compare the efficacy of transpupillary thermotherapy (TTT), indocyanine green-enhanced TTT (ICG-TTT), and photodynamic therapy (PDT) in the management of circumscribed choroidal hemangioma (CCH) and to investigate the baseline clinical features effecting treatment outcomes
Retrospective review of clinical records of 60 eyes with CCH which underwent TTT (25), ICG-TTT (22), or PDT (13). Main study outcomes were 1) final visual acuity (VA) ≤20/200, 2) <2 Snellen lines VA increase, 3) persistent subretinal fluid (SRF), and 4) <20% decrease in tumor thickness.
Multivariable factors associated with final VA ≤20/200 included longer duration of symptoms (p = 0.015), lower initial VA (p = 0.030), and presence of retinoschisis overlying the tumor (p = 0.047). Multivariable factors for <2 Snellen lines VA increase were longer duration of symptoms (p = 0.018) and previous failed treatment (p = 0.003). By multivariable analysis, the only significant factor for persistent SRF was the presence of retinoschisis (p = 0.001). Multivariable factors associated with a decrease in tumor thickness by <20% were smaller initial tumor thickness (p = 0.045) and presence of retinoschisis (p = 0.014). By Pearson Chi-Square/Fisher Exact Test, final VA ≤20/200 rates (48.0%, 13.6%, 30.8% respectively, p = 0.041) and VA improvement by <2 lines rates (64.0%, 27.3%, 38.5% respectively, p = 0.036) were significantly different between TTT, ICG-TTT, and PDT groups. However, by post hoc analysis, ICG-TTT yielded statistically better outcomes compared to TTT with respect to final visual acuity (VA) ≤20/200 (p = 0.012) and <2 Snellen lines VA increase (p = 0.012).
Longer symptom duration, previous failed treatment, lower initial VA, and presence of retinoschisis were risk factors for worse visual outcomes. Eyes with retinoschisis displayed more SRF persistence after treatment. Smaller initial tumor thickness and presence of retinoschisis were risk factors for <20% decrease in tumor thickness.
Long-term follow-up and “double layer sign” in patients affected by circumscribed choroidal hemangioma
2020, Photodiagnosis and Photodynamic Therapy
Photodynamic therapy has revolutionised the treatment of circumscribed choroidal hemangiomas. The aim of this report is to report the long-term follow-up of patients affected by circumscribed choroidal hemangioma treated using photodynamic therapy.
We retrospectively reviewed patients affected by circumscribed choroidal hemangioma examined at the Retinal Medical Department at the Eye Clinic in Florence. We studied circumscribed choroidal hemangiomas treated using photodynamic therapy with at least 1 follow-up examination. Verteporfin was administered intravenously for 10 min (6 mg/m2 body surface area). After infusion (5 min), a 689 nm laser was applied with a light dose of 50 J/cm2.
Ten eyes of 10 patients with circumscribed choroidal hemangioma who underwent Photodynamic therapy were included in our series (2 females and 8 males; average age at diagnosis 47.8 ± 9.3 yrs.; age range: 27–56 years). Five patients (5/10; 50 %) received only the photodynamic treatment whereas 5 patients (5/10; 50 %) also received other treatments (laser photocoagulation, intravitreal injection). On average, the patients received 2 photodynamic treatments (range 1–4). Four patients (4/10, 40 %) had a > 5-year follow-up; (average 4.5 ± 3.7 yrs. range 6 months – 10 years). In 2 patients we identified the “double layer sign” at the optical coherence tomography examination on circumscribed choroidal hemangioma.
In our series, photodynamic therapy was a safe and effective treatment for circumscribed choroidal hemangioma during long-term follow-up. The double layer sign, which can be detected in several choroidal pathologies, suggests common pathogenetic mechanisms for circumscribed choroidal hemangiomas and central serous chorioretinopathy/polypoidal choroidopathy spectrum disease.
Circumscribed Choroidal Hemangioma: Visual Outcome in the Pre-Photodynamic Therapy Era versus Photodynamic Therapy Era in 458 Cases
2020, Ophthalmology Retina
To analyze visual outcomes after treatment of choroidal hemangioma in the pre-photodynamic therapy (PDT) era versus PDT era.
Retrospective, comparative case series.
A total of 458 patients with circumscribed choroidal hemangioma.
Comparison of hemangioma managed in the pre-PDT (1967–2001) era versus PDT (2002–2018) era.
Visual acuity outcome.
A total of 458 tumors were treated over this 51-year period. A comparison (pre-PDT [n = 220 cases] vs. PDT [n = 238 cases]) revealed PDT era patients were of older mean age (48.9 vs. 53.8 years, P = 0.002) and were more likely to have systemic hypertension (17.7% vs. 33.8%, P < 0.001), tumor location in the macula (57.4% vs. 67.5%, P = 0.01), subretinal fluid on OCT (33.3% vs. 70.7%, P = 0.01), and greater extent of overlying lipofuscin (P = 0.001). Findings of tumor basal diameter and thickness and fluorescein and indocyanine green angiography were no different in the 2 eras. Treatment (pre-PDT vs. PDT) included argon laser photocoagulation (42.1% vs. 0.4%), PDT (0% vs. 43.8%), transpupillary thermotherapy (0% vs. 0.4%), plaque radiotherapy (7.0% vs. 5.2%), external beam radiotherapy (1.4% vs. 1.3%), enucleation (0.9% vs. 0.4%), and observation (48.6% vs. 47.6%). After treatment, patients in the PDT era demonstrated better mean logarithm of the minimum angle of resolution visual acuity (1.28 vs. 0.51, P < 0.001) (Snellen equivalent 20/400 vs. 20/63, P < 0.001). Final visual acuity was ≥20/40 for those with entering vision of ≥20/40 (59.6% vs. 74.7%, P = 0.001) and for those with entering vision of 20/50–20/200 (25.4% vs. 47.3%, P < 0.001).
Management of choroidal hemangioma in the PDT era has allowed for significantly better visual outcome compared with the pre-PDT era, with mean final visual acuity of 20/400 (pre-PDT era) versus 20/63 (PDT era).
Bilateral diffuse choroidal hemangioma in Sturge Weber syndrome: A case report highlighting the role of multimodal imaging and a brief review of the literature
2019, Journal of Current Ophthalmology
To present a patient with bilateral choroidal hemangioma in Sturge-Weber syndrome (SWS) and highlight multimodal imaging techniques for early detection and management of ocular alterations.
A 37-year-old woman with diagnosis of SWS presented to our unit. The patient had been treated with pulsed dye laser for bilateral nevus flammeus and had right leptomeningeal angiomatosis. She had glaucoma, but ultrasound biomicroscopy did not show anterior chamber or ciliary body alterations.
Enhanced depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT) showed bilateral diffuse choroidal hemangiomas in both eyes with choroidal thickness above 1000 μm. B-scan ultrasound examination showed diffuse choroidal hemangioma in both eyes, with a choroidal thickness of 1.53 mm and 1.94 mm in the right and left eye (RE, LE), respectively. Peripapillary retinal nerve fiber evaluation showed thinning of the retinal nerve fiber layer in both eyes.
This report highlights multimodal imaging techniques for the critical assessment of patients with SWS, especially in rare cases with bilateral choroidal hemangioma of the choroid. Novel imaging modalities enable optimal management and follow-up of rare conditions, and our case adds further evidence to the existing literature.
Photodynamic therapy for symptomatic circumscribed choroidal hemangioma in 22 Chinese patients: A retrospective study
2018, Photodiagnosis and Photodynamic Therapy
The purpose of this study is to describe the effects and complications of photodynamic therapy (PDT) on Chinese patients with circumscribed choroidal hemangioma (CCH). In this retrospective study, 22 CCH patients who underwent PDT performed 15 min after the injection of intravenous verteporfin (6 mg/m2)with multiple 83-second laser spots at 689 nm (50 J/cm2) were studied. Fluorescein angiography and/or indocyanine green angiography, B-scan ultrasonography and optical coherence tomography were performed in all patients. Follow-up was performed until 12 months post-treatment. All patients were treated with one session, except 1 case with prior transpupillary thermotherapy history. At the 12-month follow-up, the mean of the best corrected visual acuity (BCVA) increased from 0.40 ± 0.38 to 0.56 ± 0.42 (p < 0.05), tumors became thinner (1.96 ± 2.65 mm vs. 4.31 ± 2.04 mm) (p < 0.05), and exudative detachment were diminished. The mean fovea center thickness (FCT) decreased from 540.1 ± 470.6 to 171.6 ± 79.3 μm at the 3-month follow-up. The 12-month BCVA was correlated with prior laser treatment, symptom duration, baseline CCH diameter and thickness, baseline FCT and cystoid macular edema. One patient developed a branch retinal artery occlusion. In conclusion, PDT is an effective and safe treatment for CCH. Specific PDT protocols for CCH should be standardized. The retinal arteriole should be spared during the treatment.
Analysis of Long-term Outcomes of Radiotherapy and Verteporfin Photodynamic Therapy for Circumscribed Choroidal Hemangioma
2018, Ophthalmology Retina
To determine the long-term therapeutic outcome for different treatments of circumscribed choroidal hemangioma (CCH).
Retrospective observational study.
Patients with newly diagnosed CCH.
Observation, verteporfin (Visudyne) photodynamic therapy (PDT), lens-sparing external beam radiotherapy (LS-EBRT), or plaque brachytherapy.
Best-corrected visual acuity (BCVA) at baseline and throughout follow-up, tumor dimensions, and OCT central thickness (where available) at baseline and throughout follow-up were recorded.
There were 60 treatment-naïve consecutive cases with CCH between January 2000 and June 2014; 42 (70%) received treatment. These were LS-EBRT (23/60 [38%]; mean follow-up, 45.5 months), PDT (16/60 [27%]; mean follow-up, 38 months), and plaque radiotherapy (3/60 [5%]; mean follow-up, 92 months). Macular location, mottled or orange pigment, and absence of drusen were significantly more frequent in the treatment group. In the LS-EBRT group, median thickness reduction on ultrasound B scan was 1.6 mm (mean ± standard deviation, 1.65±1.6; range, −6.5 to +0.7). The mean ± standard deviation BCVA gain was 0.22±0.34, with >3 Snellen lines in 48% of cases. Kaplan-Meier estimates were 80% for any gain and 40% for >3 Snellen lines gain at 5 years. In the PDT group, the median decrease in thickness was 0.95 mm (mean ± standard deviation, 1.0±0.8; range, −2.5 to +0.2). The mean ± standard deviation BCVA gain was at 0.3±0.51, with >3 Snellen lines in 30% of cases. Kaplan-Meier estimates were 93% for any gain and 68% for >3 Snellen lines at 5 years. Double versus single duration PDT had more favorable outcomes with a greater reduction in tumor thickness (P = 0.04), central retinal thickness (P = 0.02), and improvement in visual acuity (median, 0.33 vs −0.05). There was no difference in decrease in tumor thickness or BCVA gain between the LS-EBRT and PDT groups. With plaque brachytherapy, the mean decrease in thickness was 2.5 mm, but BCVA loss of >2 Snellen lines was noted in all 3 cases at the end of follow-up. Radiation complications developed in 10 of 23 cases (43.5%) from the LS-EBRT group and 2 of 3 cases (67%) from the plaque brachytherapy group.
LS-EBRT is equivalent to PDT in CCH management for post-treatment BCVA and tumor thickness reduction. The risk of LS-EBRT and plaque brachytherapy was late radiation-related complications. Double duration PDT was more favorable than single duration.

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Original ArticlesProton beam irradiation of choroidal hemangiomas

Abstract

Section snippets

Patients and methods

Results

Discussion

Surv Ophthalmol

Am J Ophthalmol

Ophthalmology

Choroidal hemangioma

Semin Ophthalmol

Diagnostik und Therapie des Aderhauthämangioms

Klin Monatsbl Augenheilkd

Cavernous hemangioma of the choroid. Clinical review of 10 cases

Ophthalmologica

Circumscribed choroidal hemangiomaslong-term visual prognosis

Retina

Circumscribed choroidal hemangiomas

Arch Ophthalmol

Fluorescein angiographic findings and results of laser treatment in circumscribed choroidal hemangioma

Int Ophthalmol

Original Articles
Proton beam irradiation of choroidal hemangiomas