In, J Hari,o/ii,n CJn<ol<,~,~ Biol Phn Vol 18. pp. 679-687 0360.3016/90 $3.

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PrInted ,n the CI.S.A All nghts reserved. Cop)nght Cc 1990 Pergamon Press plc

0 Computer Applications

AN INTERACTIVE TREATMENT PLANNING SYSTEM

FOR OPHTHALMIC PLAQUE RADIOTHERAPY

MELVIN A. ASTRAHAN, PH.D.,* GARY LUXTON, PH.D.,* GABOR JOZSEF, PH.D.,*

THOMAS D. KAMPP, PH.D.,* PETER E. LIGGETT, M.D.,?
MICHAEL D. SAPOZINK M.D., PH.D.* AND ZBIGNIEW PETROVICH, M.D.*

University of Southern California School of Medicine, Los Angeles. California, USA

Brachytherapyusing removable episcleral plaques containing sealed radioisotope sources is being studied as an
alternative to enucleation in the treatment of choroidal melanoma and other tumors of the eye. Encouraging early
results have been reported, but late complications which lead to loss of vision continue to be a problem. A randomized
national study, the Collaborative Ocular Melanoma Study (COMS) is currently in progress to evaluate the procedure.
The COMS specified isotope is 12’I. Precise dosimetric calculations near the plaque may correlate strongly with
complications and could also be used to optimize isotope loading patterns in the plaques. A microcomputer based
treatment planning system has been developed for ophthalmic plaque brachytherapy. The program incorporates
an interactive, 3-dimensional, solid-surface, color-graphic interface. The program currently supports “‘1 and 19’Ir
seeds which are treated as anisotropic line sources. Collimation effects related to plaque structure are accounted
for, permitting detailed study of shielding effectiveness near the lip of a plaque. A dose distribution matrix may be
calculated in any subregion of a transverse, saggital, or coronal planar cross section of the eye, in any plane
transecting the plaque and crossing the eye diametrically, or on a spherical surface within or surrounding the eye.
Spherical surfaces may be displayed as 3-dimensional perspective projections or as funduscopic diagrams. Isodose
contours are interpolated from the dose matrix. A pointer is also available to explicitly calculate and display dose
at any location on the dosimetry surface. An interactive editing capability allows new plaque designs to be rapidly
added to the system.

I-l 25, Plaque,Choroidalmelanoma,Radiationdosimetry.

INTRODUCTION 16, 23) with relatively long lived isotopes (h0Co and ‘06Ru)
and (b) those into which sealed radioisotope sources (‘921r
Brachytherapy using lZ51 and a variety of other isotopes or lZ51) are temporarily inserted (1, 6, 12, 17, 21). The
in removable episcleral plaques is often used in the treat- COMS participants use five standard sizes of sealed source
ment of ophthalmic tumors (2,6,8, 16,20.2 I, 23). Plaque plaques (6, 12). These plaques consist of a bowl shaped
based brachytherapy permits higher tumor doses with outer shell made of a gold alloy and a seed carrier insert
greater sparing of non-involved tissues compared to x-ray made of silicone rubber. The silicone insert simplifies seed
teletherapy. Plaque therapy is more accessible, and less installation and offsets the seeds by 1 mm from the scleral
expensive, time consuming, and labor intensive than surface. The gold shell is a symmetrical segment of a
heavy charged particle teletherapy (4, 9, IO). A Phase III spherical surface which is terminated by a cylindrical lip
national study, the Collaborative Ocular Melanoma Study of about 3 mm height. The lip holds the silicone insert
(COMS), is currently comparing the efficacy of plaque and provides limited collimation of the photon flux from
brachytherapy for moderately large tumors (3 to 8 mm the plaque. Projecting from the lip are small eyelets which
height) versus enucleation. are used to suture the plaque to the sclera. Plaque di-
Ophthalmic plaques fall into two general catagories: (a) ameters of 12 mm, 14 mm, 16 mm, 18 mm and 20 mm.
those that are supplied as ophthalmic applicators (2, 3, 5, measured at the lip, are available.* ‘25I is the isotope des-

* Department of Radiation Oncology. education, research and development grant from IBM Corpo-
’ Department of Ophthalmology. ration (University of Southern California project Socrates), and
Reprint requests to: Melvin A. Astrahan. Ph.D., Department an American Cancer Society institutional Research Grant ACS-
of Radiation Oncology, University of Southern California School IRG IN-2 I-W through the USC Comprehensive Cancer Center.
of Medicine, Kenneth Norris Jr. Cancer Hospital. 1441 Eastlake The Macintosh II implementation was assisted in part by a gift
Ave.. Los Angeles. CA 90033. USA. from BSD Medical Corporation.
ilcknow/~,~~erncnt.v-Portions of the original computer system Accepted for publication 19 July 1989.
used to help develop this program were provided through an * Trachsel Dental Studio, Rochester, Minnesota, USA.

679
680 1. J. Radiation Oncology 0 Biology 0 Physics March 1990. Volume IX. Number 3

ignated (6) by the COMS. Sealed “‘1 sources in the form

of seeds+ are placed into the slots of the seed carrier. which
is then inserted into the gold shell. The COMS plaques
are pictured in Figure 1. Many alternatives to the COMS
plaques have been reported in the literature for lZiI and
“‘Ir seeds. Some ofthese alternatives permit asymmetrical
designs (17, 2 1) and/or the incorporation of hyperthermia
(1,7). Asymmetrical plaques combined with a low energy
isotope are particularly suited to treating tumors in close
proximity to the optic nerve or macula.
While initial tumor responses following ophthalmic ra-
diotherapy have been good. late complications continue
to be reported. Complications include scleral necrosis,
macular edema, cataract, neovascular glaucoma and vas-
culopathy of the retina and optic nerve (5, 8, I 1. 20, 22).
It is of interest to obtain precise dosimetry in the imme-
diate vicinity of ophthalmic plaques to determine if such
data will correlate strongly with complications of treat-
ment.
In this report we describe an ophthalmic plaque dosim-
etry program, implemented on a microcomputer work-
station, which uses a highly interactive 3-dimensional
graphics interface. The program provides detailed dosim-
etry for the COMS plaques, and has general application
to all seed carrying plaques. In particular, isotope decay, Fig. I. The plaques used in the Collaborative Ocular Melanoma
source anisotropy. inhomogeneous scatter, and collima- Study (COMS) have diameters ranging from 12 to 20 mm, and
tion provided by the lip at the edge of a plaque are ac- lip heights from 2.5 to 3.3 mm. “‘1 seeds are loaded into a
silicon carrier which is then inserted into the 0.5 mm thick gold
counted for.
alloy shell. The silicon carrier offsets the seeds by 1 mm from
the scleral surface. Six suture eyelets project from the lip of a
plaque at 30” intervals.
METHODS AND MATERIALS

The dosimetry program was originally developed on a and contents (“‘I, 19’Ir, or empty) of slots into which
personal computer,* and subsequently adapted to the sealed sources can be loaded, and the radius of the sphere
multi-window environment of an inexpensive worksta- (plaqRadius in Fig. 3) to which the plaque conforms. The
tion.” The original version was coded** using a commer- origin of the plaque’s coordinate system is the center of
cial graphics primitives ++ librarv. The current version is this sphere. Three angles define the orientation and dis-
coded*’ using the workstation’s graphics “toolbox”. The placement of each source from a standard orientation and
workstation displays 640 X 480 pixels at 72 ppi and 256 position. Referring to Figs 2 and 3. the standard position
colors per pixel. The color graphics in this article were is defined as x = -(plaqRadius + seedoffset). y = 0. z
photographed from the workstation’s video monitor. = 0. The standard orientation has the long axis of the
source parallel to the z-axis (seedTilt = 0”). The seed is
first rotated about the x-axis by seedTilt, then about the
Digitizing the coordinates of individual seeds for do- y-axis by seed N, and finally rotated about the x-axis once
simetric purposes is laborious and prone to inaccuracy. again by seed p. A plaque description also includes the
This task can be simplified by observing that the seeds thickness of the plaque on the central axis (caxHeight),
occupy fixed, standardized positions with respect to the the location of suture eyelets, and a table of 24 radii which
silicon carrier and gold shell. If the location and orien- approximate the perimeter of the gold shell. The angular
tation of the plaque is known, precise seed coordinates interval between radii is typically 15”, although they may
can be derived from a model of the plaque’s structure. A be distributed irregularly if desired. A plaque file is created
plaque data file identifies the location, length, orientation by measuring the plaque parameters and writing a com-

+ Model 671 1, 3M Corp., Medical Products Div., St. Paul. ** Turbo Pascal 3.0. 8087 version. Borland International.
MN, USA. Scotts Valley, CA. USA.
* PC-XT, IBM Corporation, Boca Raton, FL, USA. ” Halo’“, Media Cybernetics, VA. USA.
g Macintosh II, Apple Computer Inc., Sunnyvale. CA. USA. zt LightspeedC 3.0. Symantec, Bedford, MA. USA.
 Planning ophthalmic plaques 0 M. A. ASTRAHAN et al. 681

and dialog windows, and may be overridden for individual

seeds. Any combination of source activity and type is per-
mitted. In addition, patterns of slots may be added or
removed from the plaque and slot positions moved to
new locations on the plaque using the interactive graphics
interface. The plaque perimeter can be modified to in-
dicate asymmetrical characteristics such as notches and
suture eyelets. The modified plaque can be renamed and
saved to disk for future use. The interactive editing ca-
pability permits custom plaque descriptions to be rapidly
created from a library of previous patients and plaque
Y designs.

Positioning the plaque on the eye

The position of the plaque during treatment is defined
Fig. 2. The origin of a plaque’s coordinate system is the center using a spherical, solid surface, 3D perspective projection
of the sphere to which it conforms. The position and orientation of the eye. Left or right eye, anterior to posterior pole
of a slot is specified by 3 angles which describe the displacement length (apAxis, Fig. 4), the diameter of the limbus and
from a standard position and orientation. The seed is first rotated
equator, and other ocular dimensions obtained from CT,
about the x-axis by seedTilt, then rotated about the y-axis by
seed o(, and finally rotated about the x-axis once again by MRI, ultrasound and/or direct caliper measurement are
seed p. specified from menus and interactive dialogs. The eye,
and markers for anatomical structures such as optic nerve
are then dimensionally scaled to these parameters using
puter program to create the plaque file algorithmically, the size and anatomic descriptions of Newell ( 19), Last
by digitizing the plaque outline and slots from photo- (13), and the COMS. Displays for anterior, posterior, me-
graphic frontal views, and/or by editing an existing plaque dial, lateral, superior or inferior views, as well as free ro-
using interactive graphics. tation in three dimensions may be selected from a menu.
A plaque description can be modified by changing the To achieve the display speed necessary for smooth ani-
isotope loading pattern or the appearance of the plaque mation, the eye is drawn as a wire frame outline without
itself. A plaque editing window provides an expanded hidden line removal during free rotation. Calculating and
frontal view of the plaque in an interactive graphics mode. redrawing the solid-surface display requires about 2 sec-
The mouse and screen pointer are used to install or re- onds, which is too slow for animation. A “zoom” feature
move seeds from a slot by pointing at the slot and “click- allows magnification of the screen image by up to 5 times
ing” the mouse button. Standard default settings for iso- to facilitate precise positioning of the plaque. The position
tope, source activity, implant duration, and other plaque of the geometrical center of a plaque during treatment is
related parameters are modified from “pull-down” menus specified by “grabbing” the image of the plaque on the

Equator

Right eye

Fig. 4. The coordinate system used to indicate location on the

Fig. 3. Lateral view of the plaque coordinate system. A slot is surface of the eye. Latitude and longitude are specified with
initialized with its geometrical center at a standard position (x respect to the equator and prime meridean. The prime meridian
= -(plaqRadius + seedoffset), y = 0, z = 0) and oriented with begins at the posterior pole and passes through the positive
its long axis parallel to the z-axis (seedTilt = 0”). z-axis. The positive y-axis is directed “away” from the viewer.
682 I. J. Radiation Oncology 0 Biology 0 Physics March 1990. Volume 18. Number 3

screen using the mouse controlled screen pointer, and or surrounding the eye can be displayed as a 3-dimensional
“dragging” an animated, 3D wire frame outline of the perspective projection or as a funduscopic (or “retinal”)
plaque to the desired location. Alternatively, the plaque diagram. Interactive zoom and pan on the dosimetry sur-
can be automatically centered over the tumor. The ro- face is provided. Dose calculation matrices ranging from
tational orientation of the plaque with respect to its central 20 X 20 to 160 X 160 points may be selected. The matrix
axis is also specified interactively or from a dialog window. may be applied to a planar dosimetry surface in any rec-
Within the program, the position and orientation of tangular subregion ranging from 2 to 40 mm on edge.
the plaque are handled in a manner similar to that used Bilinear interpolation is used to estimate isodose contours
to describe seed locations within a plaque. The plaque is between the calculated points. A variety of color and grey
initialized in a standard geometrical position and orien- scale isodose display options are provided including a li-
tation with its center at the posterior pole of the eye. Figure brary of predefined formats covering one to four orders
4 illustrates the location ofthe poles, equator, limbus, and of magnitude. User definable formats are also available.
meridians with respect to the anatomy of the eye. The The display can be normalized to the dose at any location
latitude and longitude of the plaque center, and the ori- on the central axis of the plaque or the apex of the tumor.
entation of the plaque during treatment are converted Alternatively, the dose at any point on the dosimetry sur-
into a sequence of rotations from the standard position face can be calculated explicitly and displayed numerically
(in the local coordinate system of the eye). Referring to by “clicking” the pointer at the location. A table of dose
Figure 5, the plaque is first spun about its own central values at 1 mm intervals on the central axis of the plaque,
axis (plaquespin) to account for orientation. In the stan- and to the center of certain ocular structures is also avail-
dard geometry, the central axis of the plaque is the same able.
as the x-axis of the eye, so this involves a rotation about The dosimetry algorithm initially treats each seed as
the x-axis. The plaque is then rotated about the y-axis an unfiltered line source, located on the longitudinal axis
(plaqueTheta), and finally rotated about the x-axis once of the physical seed, in a full scatter geometry. Various
again (plaquephi) to bring its center to the desired position. dose modifying factors, taken from the literature and from
our own measurements are then applied to account for
C&dating and displu)~ing the dose distribution tissue attenuation and scatter (15) angular anisotropy ( 14,
Transverse, saggittal, or coronal planar cross-sections 25). and deviation from full scatter geometry due to the
may be requested, as well as any plane transecting the eye gold shell ( 18). The activity of each source at the start of
diametrically. These planar surfaces are displayed within treatment is specified in the plaque description. Although
a translucent eye. In addition, any spherical surface within the program defaults to a 1 hr calculation, any calculation
period may be specified. Source decay is automatically
included in the calculation. For sources which are offset
from the scleral surface, the intervening medium is pre-
sumed to be tissue equivalent. The dose calculation model
has been described previously, and compared to TLD
measurements in an acrylic phantom (17).
Collimation of the direct photon fluence from each
source by the lip of a plaque with a circular perimeter
(any of the COMS plaques) is accounted for by considering
* +X
the plaque to be in the standard geometry discussed above.
Instead of rotating the plaque and its sources, the calcu-
lation point is rotated by the inverse transformation,
bringing it to a corresponding location in the standard
geometry. In the standard coordinate system, if the x co-
ordinate of the rotated dosimetry point P (x, y, z) falls
“behind” the plane defined by the circular perimeter of
the plaque (x I -1ipPlaneX in Fig. 6) then the position
of P is compared to the structure of the gold shell. If P
Fig. 5. Lateral view of the eye coordinate system. Although the
lies outside the cylinder defined by the lip (i.e.. (y2 + z2)
operator of the program uses the more familiar terms of latitude
and longitude to describe the plaque position, within the program > lipRadius2) or if P lies within the cylinder and behind
the position and orientation of the plaque is handled as a se- the plaque (i.e. (x < 0) and (((x + eyeRadius - plaq-
quence of angular displacements from the standard position in Radius)2 + y2 + z2) > (plaqRadius + caxHeight)2)) then
the local coordinate system of the eye. The plaque is first spun the sources are completely obscured by the gold shell and
about its own central axis (plaquespin) to account for orientation.
the dose is modified by the transmission factor (for the
then rotated about the y-axis (plaqueTheta), and finally rotated
about the x-axis once again (plaquephi) to bring its center to particular isotope) through the gold. For ‘251, the trans-
the desired position. mission is considered to be zero.
 Planning ophthalmic plaques 0 M. A. ASTRAHAN etal. 683

RESULTS

The Macintosh implementation requires approximately

3 sets per seed to calculate a 40 X 40 dose matrix with
lip detection activated, and is about 20% faster when lip
detection is disabled. Interpolating the dose matrix and
generating the screen display requires from 3 to 30 sets,
depending only on the size of the display window and the
type of display surface requested (planar or 3D perspective
projection). The time required to generate a screen display
is independent of the dose matrix resolution. Although
matrices up to 160 X 160 points are available at the cost
of proportionately longer computation time, no visual
improvement in isodoses within the hypothetical tumor
volume was apparent between the 40 X 40 and 80 X 80
modes. The higher resolution modes which generated the
figures in this report are primarily intended to reduce al-
iasing in the penumbral region near the lip. A typical
plaque with 10 seeds normally requires ~60 set to cal-
Fig. 6. Diagram of the standard geometry for plaques with a
circular lip. This standard geometry simplifies the calculation culate and display a dosimetry matrix adequate for clinical
of what portion of a seed is visible from an arbitrary position P purposes, and about 1 set to generate a dose table for the
in 3-dimensional space. See text for explanation. central axis and critical structures.
The partial visibility algorithm was tested using a 16
mm diameter COMS plaque. A single 4 mCi seed of “‘1
was assigned to a slot near the center of the plaque (Fig.
If the x coordinate of P lies in front of the plaque (x 7a), near the lip (Fig. 7b), and to a radially oriented slot
> -1ipPlaneX) and P lies within the cylinder defined by near the lip of a modified plaque (Fig. 7~). The displayed
the lip, then the sources are always in direct sight, and isodose distributions are consistent with the expected
the gold shell has no direct effect. If P lies outside the shielding effects. Shielding of the sclera adjacent to the
cylinder, then the intersections of lines between P and the plaque is greatest for the seed near the lip and nonexistent
endpoints of the seed (PPl and PP2) with the plane x for the centrally located seed. Some aliasing in the pen-
= -1ipPlaneX are calculated. Lines which intersect this umbral region is evident for the radially oriented seed,
plane within the circular perimeter of the lip indicate that but is of little practical concern. This aliasing results from
the endpoint is visible from P, whereas lines which inter- the limit of five iterations imposed (to improve speed) on
sect outside the circle indicate an endpoint which is ob- the pvr calculation.
scured by the lip. If both end points of a source are visible Alternative loading patterns for the plaque were studied
there is no lip attenuation. If both endpoints are obscured, to model pre-treatment planning capability, again using
the gold transmission factor is applied. If one endpoint is the 16 mm COMS plaque loaded with lz51 seeds. The
visible and the other is obscured, the source is partially plaque was centered on the y-axis at the intersection of
visible and an iterative procedure is used to estimate the the equator and lateral (90”) meridian (Fig. 4). Dose ma-
“partial visibility ratio” (pvr = visible length t source trices were calculated in the plane z = 0 which transects
length). The gold transmission factor is applied only to both the plaque and eye. In the first case, 13 sources of
the portion of the seed which is obscured. An iterative equal activity filled all of the available slots in the plaque
algorithm was chosen to estimate the pvr in order to re- (Fig. 8a). This was compared to seven sources of equal
duce computational complexity. The dosimetry algo- activity in the peripheral ring of slots (Fig. 8b). The dose
rithms are available from the author. distributions of Figure 8 have been normalized to a value
The lip calculation currently considers only the primary of 1.0 at 6 mm above the surface of the plaque near the
photon flux from a source. Luxton et al. (17) have ob- apex of a hypothetical 5 mm tumor. While dose to the
served that backscatter from an eye phantom shielded by tumor volume appears to be similar, retinal dose appears
a plaque is about 3% of the unshielded exposure rate. This to be more homogenous for the peripheral loading pattern.
suggests that scatter into shielded regions away from the A dose-volume histogram for 1 mm3 voxels within the
penumbral region is not of great clinical significance. The eye was calculated for each case. The results indicate that
relative contribution of scatter to the penumbral region, the peripheral loading pattern increased the volume of
however, is unknown. At this time we must consider that eye tissue receiving a dose 2 4X the normalization dose
our calculation underestimates dose in the penumbral re- by only 1 mm3 while decreasing the volume 2 2X by 52
gion. mm3. For this particular geometry, the improved ho-
684 1. J. Radiation Oncology 0 Biology 0 Physics March 1990, Volume 18. Number 3

(a)
(a)

03 (b)
Fig. 8. Comparison of a peripheral loading pattern versus a uni-
form loading pattern for the COMS 16 mm diameter plaque.
The dose distribution is calculated for the plane z = 0. The
display has been normalized to a value of 1.O at 6 mm from the
plaque surface on the central axis of the plaque, near the apex
of a hypothetical tumor. The nominal position of the retina is
indicated by the inner white semi-circle, inset 1 mm from the
scleral surface. The tumor is roughly conical in shape, and is
indicated by the darkened region within the eye. Dose volume
is calculated in mm3. (a) 13 equal sources filling all available
slots. (b) 7 equal sources in the peripheral ring.

scleral dose distribution is plotted as a 3D perspective

projection in Figure 9a. The retinal dose distribution is
plotted in the manner of a funduscopic diagram in 9b.
(c) Localized areas of high dose on the sclera adjacent to each
Fig. 7. Test of the partial visibility algorithm using a single “‘1 seed, which were not readily apparent in Fig. 8b are now
source: (a) in a slot near the center of the plaque, (b) in a slot
near the lip, (c) in a modified version of the plaque with a radially
clearly seen in Fig. 9a. Outside the lip perimeter indicated
oriented slot near the lip. The plane of dose calculation is the by the yellow wire-frame in Figure 9a, a distinctive lobular
plane z = 0. pattern is observed in the 0.1 to 0.7 relative dose range.
This pattern apparently results from partial visibility of
mogeneity of the peripheral loading pattern was achieved alternating sources. Figures 10a & lob display views of
at the cost of a slight increase in dose to the lens and to the retinal dose from anterior and posterior vantage points.
the sclera near the peripheral edge of the plaque. Figure 1Oc is identical to lob except that lip collimation
The dose distribution on the scleral surface and the is ignored. The dose distribution in Figure 1Oc suggests
retina (assumed to be 1 mm inset from the scleral surface) that the lip, rather than anisotropy is the source of the
are modeled in Figures 9 & 10 for the plaque depicted in lobular pattern. For this particular geometry and orien-
Figure 8b. All dosimetry is normalized as in Figure 8. The tation, in which the plaque is adjacent to the optic nerve,
 Planning ophthalmic plaques 0 M. A. ASTRAHAN etal. 685

(4 (a)

0-3
(b)
Fig. 9. Dose distributions on the scleral and retinal surfaces for
the COMS 16 mm plaque with 7 equal ‘25I sources in the pe-
ripheral ring. The display has been normalized to a value of 1.O
at 6 mm from the plaque surface on the central axis of the plaque.
(a) 3-dimensional perspective projection view of the scleral dose
distribution. (b) Funduscopic diagram of dose to the retina.

the calculated dose to the center of the optic disc in Figure

1Oc is roughly twice that of 1Ob.

DISCUSSION
This program can potentially be applied to optimize
plaque design, seed placement, and treatment planning.
For example, in the geometry depicted in Figure 10, if
(c)
the dose at the 6 mm normalization point were 100 Gy, 1
Fig. 10. Retinal dose distributions for the COMS 16 mm plaque
then the estimated dose to the center of the optic disc
with 7 equal ‘*‘I sources in the peripheral ring. The display has
would be about 80 Gy without accounting for lip colli- been normalized to a value of 1.0 at 6 mm from the plaque
mation, and about half that when lip collimation is in- surface on the central axis of the plaque. (a) and (b) are 3-di-
cluded. If a 40 Gy variation in dose to a critical structure mensional perspective projection views from anterior and pos-
were associated with a significant difference in compli- terior vantage points. (c) is identical to (b) except that lip colli-
mation effects have been ignored.
cation rate, the ability to account for lip collimation will
be important. In addition to plaque orientation, the effects
of using mixed isotopes, and/or seeds of unequal activity
can be modelled. This may be of value in reusing sources matrix provides rapid feedback for plaque design, and
and tailoring the dose distribution to an irregular tumor permits detailed study of dose gradients within structures
volume. The ability to immediately display point dose such as the lens, optic disc or macula.
values without necessarily calculating a complete dose Absolute dosimetry for plaques containing 19*Ir seeds,
686 1. J. Radiation Oncology 0 Biology 0 Physics March 1990, Volume 18. Number 3

and relative dosimetry for “‘1 seeds, were compared to ware and software technology can be rapidly and suc-
TLD measurements in an acrylic phantom for the cal- cessfully applied to clinical dosimetry tasks.
culational model used in this program by Luxton et al. There are several aspects of the current dosimetry sys-
(17). The dosimetry for 1251 seeds, however, should be tem which require refinement prior to clinical implemen-
considered only approximate at this time. Recent Monte tation. The generalized approximation of intraocular
Carlo evaluations by Williamson (24) suggest that char- anatomy within a spherical globe may be too imprecise
acteristic X rays from the titanium seed capsule may lead for many variants of human ocular anatomy. Digitization
to a 7% overestimate of the specific dose constant when of the tumor perimeter from fundus photography, esti-
calibration is performed in air. These low energy photons mation of the 3-dimensional tumor volume from se-
are rapidly absorbed in water-like media and therefore quential CT or MRI images, and display of the 3-dimen-
have negligible contribution to tissue dose at distances sional tumor volume within a translucent eye would be
greater than 0.5 mm. Williamson (24) suggests a specific desirable additions. These would provide visual aids dur-
dose constant (the ratio of absolute dose rate at 1 cm on ing plaque positioning and permit correlation of isodose
the transverse bisector of a seed in a specific medium to surfaces with actual tumor and normal tissue contours.
the source strength) of 0.909 for the model 6711 seed. Surgical reproduction of the preplanned plaque orienta-
This is about 14% lower than the 1.035 value recom- tion and location could be difficult to achieve. If the source
mended by Ling et al. (15) for the same model seed. In locations are fixed relative to the suture eyelets on the
light of the present uncertainties concerning the absolute plaque, however. and the spatial location of the suture
dosimetry of “‘1 seeds all dose distributions reported here eyelets relative to real anatomical landmarks, such as the
were normalized to a point on the central axis of the limbus, can be specified, precise surgical placement may
plaque, 6.0 mm from the plaque surface, and near the be facilitated. Three-dimensional isodose surface displays
apex of a hypothetical 5 mm tumor. This represents a and loading optimization based on available isotope re-
typical dose specification point at this institution and by sources would also be desirable. The lip collimation al-
the COMS. gorithm currently assumes a circular lip. This could be
The multi-window, 3-dimensional graphics interface refined to handle lips of arbitrarily shaped perimeters. The
provides an intuitive environment for both the physicist COMS plaques use a silicone rubber carrier to offset the
and physician to work within. Goitein and Miller (9) used sources by 1 mm from the sclera. Our model presently
a similar approach for planning proton therapy of the considers this intervening medium to be tissue equivalent.
eye. This earlier work was implemented in FORTRAN For the low energy photons from lz51 seeds, photoelectric
on a computer89 and required about 1.3 full-time-equiv- attenuation and scatter characteristics in silicone rubber
alent (FTE) man-years to implement. The program de- could vary significantly from tissue and probably need to
scribed here was developed in about 0.4 FTE man-years be accounted for. Dose resulting from scatter into the
with the aid of the ROM “toolbox” functions built into penumbral region close to the plaque perimeter is not
the Macintosh computer. Since the program adheres to modelled and may be of significance as well. We are pres-
the recommended user interface guidelines. it is simple ently adding these capabilities to the dosimetry system
to learn and use, and is an example of how this new hard- reported here.

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Malignant intraocular tumors. Cancer 49:578-585; 1982. therapy for intraocular tumors. Arch. Ophthalmol. 103:
3. Chan, B.; Rotman, M.; Randall, G. J. Computerized do- 1574-1578; 1985.
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