Evaluation of the surgical learning curve for I-125 episcleral plaque placement for the treatment of posterior uveal melanoma: a two decade review
Identifieur interne : 001E71 ( Pmc/Checkpoint ); précédent : 001E70; suivant : 001E72Evaluation of the surgical learning curve for I-125 episcleral plaque placement for the treatment of posterior uveal melanoma: a two decade review
Auteurs : Nisha V. Shah [États-Unis] ; Samuel K. Houston [États-Unis] ; Timothy G. Murray [États-Unis] ; Arnold M. Markoe [États-Unis]Source :
- Clinical Ophthalmology (Auckland, N.Z.) [ 1177-5467 ] ; 2012.
Abstract
To evaluate the surgical learning curve in episceral plaque brachytherapy placement in the management of posterior uveal melanoma.
A retrospective chart review of two cohorts of 250 consecutive patients undergoing plaque placement for posterior uveal melanoma from 2002 to 2004 and from 2008 to 2009 was conducted. The plaque–tumor apposition rates verified by intraoperative echography were evaluated and correlated with surgical volume over a 19-year period.
In an initial study of 29 consecutive patients undergoing plaque placement from January 1992 to January 1995, a suboptimal plaque placement rate of 21% (n = 29) was identified. This percentage declined to 12% (n = 100) from January 2002 to January 2004, and further declined to 4% (n = 150) from June 2008 to August 2009. The tumor–plaque apposition rates for these three groups were 79% (1992–1995), 88% (2002–2004), and 96% (2008–2009). An estimated surgical volume of 1275 cases was performed to achieve a >90% precision rate for first application of primary plaque centration.
There are challenges to mastering the precise placement of radioactive plaques for posterior uveal melanoma. We have demonstrated a significant learning curve for plaque placement techniques, and have emphasized the importance of intraoperative ultrasound in the verification of plaque placement, thus allowing for intraoperative repositioning.
Url:
DOI: 10.2147/OPTH.S30307
PubMed: 22536035
PubMed Central: 3334212
Affiliations:
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<author><name sortKey="Markoe, Arnold M" sort="Markoe, Arnold M" uniqKey="Markoe A" first="Arnold M" last="Markoe">Arnold M. Markoe</name>
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<front><div type="abstract" xml:lang="en"><sec><title>Purpose</title>
<p>To evaluate the surgical learning curve in episceral plaque brachytherapy placement in the management of posterior uveal melanoma.</p>
</sec>
<sec><title>Methods</title>
<p>A retrospective chart review of two cohorts of 250 consecutive patients undergoing plaque placement for posterior uveal melanoma from 2002 to 2004 and from 2008 to 2009 was conducted. The plaque–tumor apposition rates verified by intraoperative echography were evaluated and correlated with surgical volume over a 19-year period.</p>
</sec>
<sec><title>Results</title>
<p>In an initial study of 29 consecutive patients undergoing plaque placement from January 1992 to January 1995, a suboptimal plaque placement rate of 21% (n = 29) was identified. This percentage declined to 12% (n = 100) from January 2002 to January 2004, and further declined to 4% (n = 150) from June 2008 to August 2009. The tumor–plaque apposition rates for these three groups were 79% (1992–1995), 88% (2002–2004), and 96% (2008–2009). An estimated surgical volume of 1275 cases was performed to achieve a >90% precision rate for first application of primary plaque centration.</p>
</sec>
<sec><title>Conclusion</title>
<p>There are challenges to mastering the precise placement of radioactive plaques for posterior uveal melanoma. We have demonstrated a significant learning curve for plaque placement techniques, and have emphasized the importance of intraoperative ultrasound in the verification of plaque placement, thus allowing for intraoperative repositioning.</p>
</sec>
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<journal-id journal-id-type="iso-abbrev">Clin Ophthalmol</journal-id>
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<article-id pub-id-type="doi">10.2147/OPTH.S30307</article-id>
<article-id pub-id-type="publisher-id">opth-6-447</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Original Research</subject>
</subj-group>
</article-categories>
<title-group><article-title>Evaluation of the surgical learning curve for I-125 episcleral plaque placement for the treatment of posterior uveal melanoma: a two decade review</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Shah</surname>
<given-names>Nisha V</given-names>
</name>
<xref ref-type="aff" rid="af1-opth-6-447">1</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Houston</surname>
<given-names>Samuel K</given-names>
</name>
<xref ref-type="aff" rid="af1-opth-6-447">1</xref>
</contrib>
<contrib contrib-type="author"><name><surname>Murray</surname>
<given-names>Timothy G</given-names>
</name>
<xref ref-type="aff" rid="af1-opth-6-447">1</xref>
<xref ref-type="aff" rid="af2-opth-6-447">2</xref>
<xref ref-type="corresp" rid="c1-opth-6-447"></xref>
</contrib>
<contrib contrib-type="author"><name><surname>Markoe</surname>
<given-names>Arnold M</given-names>
</name>
<xref ref-type="aff" rid="af2-opth-6-447">2</xref>
</contrib>
</contrib-group>
<aff id="af1-opth-6-447"><label>1</label>
Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA</aff>
<aff id="af2-opth-6-447"><label>2</label>
Department of Radiation Oncology, University of Miami Miller School of Medicine, Miami, FL, USA</aff>
<author-notes><corresp id="c1-opth-6-447">Correspondence: Timothy Murray, Bascom Palmer Eye Institute, 900 NW 17th Street, Miami, FL 33136, USA, Tel +1 305 326 6166, Fax +1 305 326 6417, Email <email>tmurray@med.miami.edu</email>
</corresp>
</author-notes>
<pub-date pub-type="collection"><year>2012</year>
</pub-date>
<pmc-comment>Dove Press titles changed from ppub to collections in 2009.
Fake ppub written to satisfy Coll Date Type=ppub</pmc-comment>
<pub-date pub-type="ppub"><year>2012</year>
</pub-date>
<pub-date pub-type="epub"><day>20</day>
<month>3</month>
<year>2012</year>
</pub-date>
<volume>6</volume>
<fpage>447</fpage>
<lpage>452</lpage>
<permissions><copyright-statement>© 2012 Shah et al, publisher and licensee Dove Medical Press Ltd.</copyright-statement>
<copyright-year>2012</copyright-year>
<license><license-p>This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.</license-p>
</license>
</permissions>
<abstract><sec><title>Purpose</title>
<p>To evaluate the surgical learning curve in episceral plaque brachytherapy placement in the management of posterior uveal melanoma.</p>
</sec>
<sec><title>Methods</title>
<p>A retrospective chart review of two cohorts of 250 consecutive patients undergoing plaque placement for posterior uveal melanoma from 2002 to 2004 and from 2008 to 2009 was conducted. The plaque–tumor apposition rates verified by intraoperative echography were evaluated and correlated with surgical volume over a 19-year period.</p>
</sec>
<sec><title>Results</title>
<p>In an initial study of 29 consecutive patients undergoing plaque placement from January 1992 to January 1995, a suboptimal plaque placement rate of 21% (n = 29) was identified. This percentage declined to 12% (n = 100) from January 2002 to January 2004, and further declined to 4% (n = 150) from June 2008 to August 2009. The tumor–plaque apposition rates for these three groups were 79% (1992–1995), 88% (2002–2004), and 96% (2008–2009). An estimated surgical volume of 1275 cases was performed to achieve a >90% precision rate for first application of primary plaque centration.</p>
</sec>
<sec><title>Conclusion</title>
<p>There are challenges to mastering the precise placement of radioactive plaques for posterior uveal melanoma. We have demonstrated a significant learning curve for plaque placement techniques, and have emphasized the importance of intraoperative ultrasound in the verification of plaque placement, thus allowing for intraoperative repositioning.</p>
</sec>
</abstract>
<kwd-group><kwd>intraoperative ultrasound</kwd>
<kwd>brachytherapy</kwd>
<kwd>ocular oncology</kwd>
</kwd-group>
</article-meta>
</front>
<floats-group><fig id="f1-opth-6-447" position="float"><label>Figure 1</label>
<caption><p>Reposition rates from 1992–1999.</p>
<p><bold>Notes:</bold>
Graph shows the declining trend (<italic>P</italic>
= 0.007) of suboptimal plaque placement from January 1992 to August 2009 (17.6 years) performed by the same surgeon. Rates correlate to consecutive patients undergoing plaque placement for posterior uveal melanoma from January 1992 to January 1995 (n = 29), January 2002 to January 2004 (n = 100), and June 2008 to August 2009 (n = 150).</p>
</caption>
<graphic xlink:href="opth-6-447f1"></graphic>
</fig>
<fig id="f2-opth-6-447" position="float"><label>Figure 2</label>
<caption><p>Cumulative number of plaque cases and precision trend.</p>
<p><bold>Notes:</bold>
Graph shows the trend in the cumulative number of cases involving plaque placement over a 19-year period. Mean number of cases in study window was 85 cases/year. The linear trend is matched with the precision percentage in initial plaque placement, indicating that plaque precision rates increase as surgical volume increases.</p>
</caption>
<graphic xlink:href="opth-6-447f2"></graphic>
</fig>
<table-wrap id="t1-opth-6-447" position="float"><label>Table 1</label>
<caption><p>Group 2 patient characteristics – plaque reposition (12/100)</p>
</caption>
<table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1">Patient</th>
<th align="left" valign="top" rowspan="1" colspan="1">Age</th>
<th align="left" valign="top" rowspan="1" colspan="1">Gender</th>
<th align="left" valign="top" rowspan="1" colspan="1">Size</th>
<th align="left" valign="top" rowspan="1" colspan="1">Location</th>
<th align="left" valign="top" rowspan="1" colspan="1">Eye</th>
<th align="left" valign="top" rowspan="1" colspan="1">Plaque displacement</th>
</tr>
</thead>
<tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">1</td>
<td align="left" valign="top" rowspan="1" colspan="1">42</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Ciliochoridal</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Nasal</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">2</td>
<td align="left" valign="top" rowspan="1" colspan="1">76</td>
<td align="left" valign="top" rowspan="1" colspan="1">F</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Ciliochoridal</td>
<td align="left" valign="top" rowspan="1" colspan="1">OS</td>
<td align="left" valign="top" rowspan="1" colspan="1">Superior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">3</td>
<td align="left" valign="top" rowspan="1" colspan="1">78</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Macular w/basal extension</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Superior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">4</td>
<td align="left" valign="top" rowspan="1" colspan="1">92</td>
<td align="left" valign="top" rowspan="1" colspan="1">F</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Choroid</td>
<td align="left" valign="top" rowspan="1" colspan="1">OS</td>
<td align="left" valign="top" rowspan="1" colspan="1">Decentered</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">5</td>
<td align="left" valign="top" rowspan="1" colspan="1">80</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Choroid</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Posterio-inferior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">6</td>
<td align="left" valign="top" rowspan="1" colspan="1">92</td>
<td align="left" valign="top" rowspan="1" colspan="1">F</td>
<td align="left" valign="top" rowspan="1" colspan="1">Large</td>
<td align="left" valign="top" rowspan="1" colspan="1">Ciliochoridal</td>
<td align="left" valign="top" rowspan="1" colspan="1">OS</td>
<td align="left" valign="top" rowspan="1" colspan="1">Decentered</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">7</td>
<td align="left" valign="top" rowspan="1" colspan="1">83</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Choroidal (amelanotic)</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Anterior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">8</td>
<td align="left" valign="top" rowspan="1" colspan="1">51</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Macula</td>
<td align="left" valign="top" rowspan="1" colspan="1">OS</td>
<td align="left" valign="top" rowspan="1" colspan="1">Decentered</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">9</td>
<td align="left" valign="top" rowspan="1" colspan="1">60</td>
<td align="left" valign="top" rowspan="1" colspan="1">F</td>
<td align="left" valign="top" rowspan="1" colspan="1">Large</td>
<td align="left" valign="top" rowspan="1" colspan="1">Ciliary body</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Superior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">10</td>
<td align="left" valign="top" rowspan="1" colspan="1">72</td>
<td align="left" valign="top" rowspan="1" colspan="1">F</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Juxtapapillary</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Decentered</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">11</td>
<td align="left" valign="top" rowspan="1" colspan="1">57</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Macula</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Inferior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">12</td>
<td align="left" valign="top" rowspan="1" colspan="1">39</td>
<td align="left" valign="top" rowspan="1" colspan="1">F</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Macula with juxtapapillary component</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Inferior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1">Mean = 68</td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
</tr>
</tbody>
</table>
<table-wrap-foot><fn id="tfn1-opth-6-447"><p><bold>Notes:</bold>
Twelve patients required plaque repositioning from January 2002 to January 2004 (Group 2). Eighty-five percent of these tumors were medium-sized. On primary placement of plaque, ultrasound showed that 4/12 plaques were decentered, 3/12 plaques were displaced superiorly, 2/12 were displaced inferiorly, 1/12 anteriorly, 1/12 nasally, and 1/12 postero-inferiorly. Tumor sizes ranged from medium (10/12) to large (2/12). Mean plaque size was 18.8 mm (range: 14–20 mm). Average follow-up time after plaque placement was 53 months (range: 4–101 months) of which no patients were shown to have tumor recurrence or metastasis. Medium tumors 2.5–10 mm thickness; large tumors >10 mm thickness.</p>
</fn>
</table-wrap-foot>
</table-wrap>
<table-wrap id="t2-opth-6-447" position="float"><label>Table 2</label>
<caption><p>Group 3 patient characteristics – plaque reposition (4/150)</p>
</caption>
<table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1">Patient</th>
<th align="left" valign="top" rowspan="1" colspan="1">Age</th>
<th align="left" valign="top" rowspan="1" colspan="1">Gender</th>
<th align="left" valign="top" rowspan="1" colspan="1">Size</th>
<th align="left" valign="top" rowspan="1" colspan="1">Location</th>
<th align="left" valign="top" rowspan="1" colspan="1">Eye</th>
<th align="left" valign="top" rowspan="1" colspan="1">Plaque displacement</th>
</tr>
</thead>
<tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">1</td>
<td align="left" valign="top" rowspan="1" colspan="1">60</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Large</td>
<td align="left" valign="top" rowspan="1" colspan="1">Diffuse</td>
<td align="left" valign="top" rowspan="1" colspan="1">OS</td>
<td align="left" valign="top" rowspan="1" colspan="1">Decentered</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">2</td>
<td align="left" valign="top" rowspan="1" colspan="1">42</td>
<td align="left" valign="top" rowspan="1" colspan="1">F</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Macula</td>
<td align="left" valign="top" rowspan="1" colspan="1">OS</td>
<td align="left" valign="top" rowspan="1" colspan="1">Inferior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">3</td>
<td align="left" valign="top" rowspan="1" colspan="1">54</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Large</td>
<td align="left" valign="top" rowspan="1" colspan="1">Not specified</td>
<td align="left" valign="top" rowspan="1" colspan="1">OD</td>
<td align="left" valign="top" rowspan="1" colspan="1">Decentered</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1">4</td>
<td align="left" valign="top" rowspan="1" colspan="1">66</td>
<td align="left" valign="top" rowspan="1" colspan="1">M</td>
<td align="left" valign="top" rowspan="1" colspan="1">Medium</td>
<td align="left" valign="top" rowspan="1" colspan="1">Not specified</td>
<td align="left" valign="top" rowspan="1" colspan="1">OS</td>
<td align="left" valign="top" rowspan="1" colspan="1">Superior</td>
</tr>
<tr><td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1">Mean = 55.5</td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
<td align="left" valign="top" rowspan="1" colspan="1"></td>
</tr>
</tbody>
</table>
<table-wrap-foot><fn id="tfn2-opth-6-447"><p><bold>Notes:</bold>
Data from four patients that required plaque repositioning from June 2008 to August 2009 (Group 3). Tumor sizes were medium in 50% of cases and large in the other 50%. On primary placement of plaque, ultrasound showed that 2/4 plaques were suboptimally positioned, 1/4 plaques were displaced inferiorly, and 1/4 plaques were displaced superiorly. Mean plaque size was 19.75 mm (range: 16–22 mm). Average follow-up time after plaque placement was 21.25 months (range: 1–36 months) of which no patients were shown to have tumor recurrence or metastasis. Medium tumors: 2.5–10 mm thickness; large tumors >10 mm thickness.</p>
</fn>
</table-wrap-foot>
</table-wrap>
</floats-group>
</pmc>
<affiliations><list><country><li>États-Unis</li>
</country>
<region><li>Floride</li>
</region>
</list>
<tree><country name="États-Unis"><region name="Floride"><name sortKey="Shah, Nisha V" sort="Shah, Nisha V" uniqKey="Shah N" first="Nisha V" last="Shah">Nisha V. Shah</name>
</region>
<name sortKey="Houston, Samuel K" sort="Houston, Samuel K" uniqKey="Houston S" first="Samuel K" last="Houston">Samuel K. Houston</name>
<name sortKey="Markoe, Arnold M" sort="Markoe, Arnold M" uniqKey="Markoe A" first="Arnold M" last="Markoe">Arnold M. Markoe</name>
<name sortKey="Murray, Timothy G" sort="Murray, Timothy G" uniqKey="Murray T" first="Timothy G" last="Murray">Timothy G. Murray</name>
<name sortKey="Murray, Timothy G" sort="Murray, Timothy G" uniqKey="Murray T" first="Timothy G" last="Murray">Timothy G. Murray</name>
</country>
</tree>
</affiliations>
</record>
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