ROSE EYELID BRACHYTHERAPY MOULD

1. ROSE CASE
MOULD BRACHY UPPER EYELID
RADIATION ONCOLOGY
SIMULATION TO EXECUTION
DR KANHU CHARAN PATRO

2. HISTORY
• RIGHT UPPER EYELID MASS SINCE 2 YEARS TOWARDS
LATERAL CANTHUS OF THE EYE

3. DIAGNOSIS BY LOCAL OPHTHALMIC SURGEON
• Right upper eyelid Yellowish nodular mass
• 8*5mm in size
• Smooth surface
• No cilia loss
• Lid margin normal
• No induration

4. PREOP- IMAGES

5. EXICISIONAL BIOPSY
• Outside by EYE surgeon

6. H/P REPORT

7. IHC REPORT
• Malignant adnexal tumor possibly sebaceous
carcinoma, lobular variant
• IHC
– Positive for PANCK,EMA,BEREP4,CK5/6,P63
– MSH2 shows retained nuclear positivity
• IHC favors of SEBACEOUS CARCINOMA

8. NECK NODE EVALUATION
• NON SPECIFIC LYMPHADENOPATHY
– MRI
– USG
– CT

9. STAGING

10. FINAL DIAGNOSIS
• Sebaceous carcinoma of Rt upper eye lid –post
excional biopsy
• Margin not commented
• pT1NOMO

11. TUMOR BOARD PLAN
• Brachytherapy
• MOULD
• Dose

12. REQUIREMENTS
FOR MOULD PREPARATION
• Wax (5mm thickness)
• Thermoplastic Mask
• Hot water
FOR BRACHY
• Lead slice
• 1 mm wax slices
• 0.5mm wax slices
• Catheter tubes
• Copper wires
• Local anaesthesia drops
(0.5% AUROCAINE)
• Refresh tear drops

13. MOULD PREPARATION

14. EYELID MOULD
• 2 types of eyelid mould
• One has to be with lead wrapped around
around by wax for treatment purpose
• Another one just made with wax for planning
CT.

15. • Eyelid mould made with lead of 5 mm
thickness.
• Trim according to shape of eyeball
• Lead has to be covered with wax all around to
prevent local reactions and direct contact with
ocular surface.
MOULD WITH WAX

16. BEFORE PLACING THE MOULD INTO EYE
• Instil 1 drop of local anaesthesia i.e
PROPARACAINE 0.5% solution in the eye.

17. LOCAL ANAESTHETIC

18. Laed block placing

19. PLACING MOULD CORRECTLY TO COVER THE EYEBALL

20. SECURING THE MOULD BY MICROPORE

21. GROOVING AND FIXING WITH FEWI KWIK

22. FINAL MOULD

23. • Copper wire has to be placed over the scar
area to delineate the area of interest.
COPPER WIRE

24. MARK THE SCAR AREA WITH COPPER WIRE

25. PLANNING CT
• 1 MM SLICE
• SUPINE
• WITH MOULD
• WITH OUT BLOCK
• ONLY BLOCK THICK WAX
• VERTEX TO CLAVICLE
• MULTIPLANNAR

26. CATHETER NUMBERING

27. OAR- ANTERIOR CHAMBER

28. OAR-LACRIMAL

29. OAR-LENS

30. OAR-EYE BALL

31. CTV-SCAR

32. WAX

33. TARGET DELINEATION
• Clinical Target Volume (CTV-scar) are usually
performed by clinical examination aided by imaging
and intraoperative endings.
• In brachytherapy, typically no additional margin is
required to ensure that the CTV receives the planned
dose and therefore.
• Unlike external beam irradiation, CTV and PTV
(Planning Target Volume) are considered equivalent,
so no PTV

34. DOSE SELECTION

35. DOSE SELECTION
• 4GY
• TWICE DAILY
• 13/14 FRACTIONS
• ALPHA/BETA-10

36. TREATMENT GAP

37. PLANNING
• ACCURATELY MEASURED CATHTER LENGTH BEFORE CT
• CATHTER NUMBERING AND MARKED
• CATHTER RECONSTRUCTION
• IPSA

38. TARGET DOSE EVALUATION

39. TARGET DOSE EVALUATION

40. TARGET DOSE EVALUATION
• CTV coverage is adequate (i.e., D90 is at least 90% of
the prescribed dose)
• The prescription dose is usually the minimum dose
received by the CTV or a CTV surrogate (i.e., the D90 >
100, V100 > 90%)
• DNR should be equal or lower than 0.36 and in IMBT
(intensity modulated Brachytherapy) 0.42
• Dose non-uniformity ratio (DNR= V100/V150)
• The optimal spacing between applicators is <15 mm

41. TARGET DOSE EVALUATION
COVERAGE INDEX
 CTV VOLUME 0.79CC DESIRABLE
 DNR INDEX V150 / V100 = 24.27/92.2 =0.26 0.36 T0 0.5
 D90
4Gy >90%-100%
 V100
92.2% >90%
 V150
24.27% ALARA
 V200
2.86% ALARA
 V300
0.01% ALARA

42. Intra oral Prosthesis
LEAD BLOCK WRAPPED WITH WAX
PREVENT BACK SCATTER

43. REVIEW LITERATURE- BLOCK

44. SEPARATING THE EYEBALL

45. TREATMENT POSITIONING

46. INTRATREATMENT CARE
• REFRESH TEAR DROPS
• MOXIFLOXACIN EYE DROPS IF MILD CONJUNCTIVITIS

47. ALL SITES

48. CATHETER IN SITU

49. ISODOSE- CORONAL

50. 3D

51. DOSE VOLUME HISTOGRAM

52. DOSE STATISTICS TABLE

53. ISODESE- PERCENTAGE

54. ISODESE- DOSE

55. OAR EVALUATION

56. POST TREATMENT CARE
• EYE HYGIENE
• SOS ANALGESICS
• COUNSEL ABOUT THE UPCOMING REACTIONS

57. FOLLOW UP
1. FOLLOW UP AT EVERY WEEK
2. LOCAL EXAMINATION

58. AT 15 DAYS

59. AT 15 DAYS

60. AT 20 DAYS

61. AT 1 MONTH

62. AT 5TH WEEK

63. AT 6TH WEEK

64. AT 7TH WEEK

65. AT 8TH WEEK

66. AT 9TH WEEK

67. AT 9TH WEEK

68. REVIEW LITERATURE

69. REVIEW LITERATURE

70. REVIEW LITERATURE

71. SPECIAL ACKNOWLEDGEMENT
DR ARYA BUNIDUTTA

72. REVIEW LITERATURE

73. REVIEW LITERATURE

74. REVIEW LITERATURE

75. REVIEW LITERATURE

76. SUMMARY
• Follow GEC-ESTRO guidelines
• Train yourself
• Follow steps
• Wires should not touch necked to any surface
• Use lead with wax wrap
• Reactions usually observed after treatment- do not
get panic , wait
• Counsel

77. ACKNOWLEDGEMENT
1. DR P S BHATTACHARYYA
2. DR V K R REDDY
3. DR M MRITYUNJYA
1. AKETI SRINU
2. DR A ANIL KUMAR
3. SENTHINATHAN
4. BHOOPATHI RAJAN
5. KARUNAKARAN
1. DR MOHANPRIYA A
2. DR KEERTHIGA K
3. DR KAVYA LAKSHMI
4. DR DONA VINCENT
5. DR BHARGAVA KRISHNA
1. SISTER SARITHA