title: A Multidisciplinary Orbit-Sparing Treatment Approach That Includes Proton Therapy for Epithelial Tumors of the Orbit and Ocular Adnexa.
abstract: OBJECTIVE
  Postoperative radiation is often indicated in the treatment of malignant epithelial tumors of the orbit and ocular adnexa. We present details of radiation technique and toxicity data after orbit-sparing surgery followed by adjuvant proton radiation therapy.
  
  
  METHODS
  Twenty patients underwent orbit-sparing surgery followed by proton therapy for newly diagnosed malignant epithelial tumors of the lacrimal gland (n=7), lacrimal sac/nasolacrimal duct (n=10), or eyelid (n=3). Tumor characteristics, treatment details, and visual outcomes were obtained from medical records. Acute and chronic toxicity were prospectively scored using Common Terminology Criteria for Adverse Events version 4.0.
  
  
  RESULTS
  The median radiation dose was 60 Gy(RBE) (relative biological effectiveness; [range 50-70 Gy]); 11 patients received concurrent chemotherapy. Dose to ipsilateral anterior optic structures was reduced in 13 patients by having them gaze away from the target during treatment. At a median follow-up time of 27.1 months (range 2.6-77.2 months), no patient had experienced local recurrence; 1 had regional and 1 had distant recurrence. Three patients developed chronic grade 3 epiphora, and 3 developed grade 3 exposure keratopathy. Four patients experienced a decrease in visual acuity from baseline but maintained vision sufficient to perform all activities of daily living without difficulty. Patients with grade ≥3 chronic ocular toxicity had higher maximum dose to the ipsilateral cornea (median 46.3 Gy[RBE], range 36.6-52.7 Gy[RBE] vs median 37.4 Gy[RBE], range 9.0-47.3 Gy(RBE); P=.017).
  
  
  CONCLUSIONS
  Orbit-sparing surgery for epithelial tumors of the orbit and ocular adnexa followed by proton therapy successfully achieved disease control and was well tolerated. No patient required orbital exenteration or enucleation. Chronic grade 3 toxicity was associated with high maximum dose to the cornea. An eye-deviation technique can be used to limit the maximum corneal dose to <35 Gy(RBE).
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Emma B
authors.initials: EB
authors.lastname: Holliday
authors.affiliation: Orbital Oncology and Ophthalmic Plastic Surgery Program, Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Bita
authors.initials: B
authors.lastname: Esmaeli
authors.affiliation: School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas.
authors.forename: Jamie
authors.initials: J
authors.lastname: Pinckard
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Adam S
authors.initials: AS
authors.lastname: Garden
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: David I
authors.initials: DI
authors.lastname: Rosenthal
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: William H
authors.initials: WH
authors.lastname: Morrison
authors.affiliation: Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Merrill S
authors.initials: MS
authors.lastname: Kies
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: G Brandon
authors.initials: GB
authors.lastname: Gunn
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: C David
authors.initials: CD
authors.lastname: Fuller
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Jack
authors.initials: J
authors.lastname: Phan
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Beth M
authors.initials: BM
authors.lastname: Beadle
authors.affiliation: Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Xiarong Ronald
authors.initials: XR
authors.lastname: Zhu
authors.affiliation: Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
authors.forename: Xiaodong
authors.initials: X
authors.lastname: Zhang
authors.affiliation: Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: sjfrank@mdanderson.org.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Frank
mesh_terms: D000328:Adult; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use; D002277:Carcinoma / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000601:surgery*; D003528:Carcinoma, Adenoid Cystic / Q000532:radiotherapy / Q000601:surgery; D002294:Carcinoma, Squamous Cell / Q000532:radiotherapy / Q000601:surgery; D003315:Cornea / Q000528:radiation effects; D005142:Eyelid Neoplasms / Q000532:radiotherapy / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007765:Lacrimal Apparatus; D008297:Male; D008875:Middle Aged; D009915:Orbit; D009918:Orbital Neoplasms / Q000000981:diagnostic imaging / Q000532:radiotherapy* / Q000601:surgery*; D059351:Organ Sparing Treatments / Q000379:methods*; D058958:Organs at Risk; D061766:Proton Therapy / Q000009:adverse effects / Q000379:methods*; D011832:Radiation Injuries; D011859:Radiography; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant / Q000379:methods; D012062:Relative Biological Effectiveness; D013997:Time Factors; D014792:Visual Acuity / Q000528:radiation effects
chemical_list: D000970:Antineoplastic Agents