Eye

 ​  __Malignant melanoma__ is the most common primary malignant tumor of the eye, the overall incidence of uveal melanoma is only 5 to 7 cases per million people each year. Average age at diagnosis is 55 years old. Tumors of the posterior uvea account for more than 90% of cases, with the majority being choroidal melanoma. 3
 * < Epidemiology: ||<  __Basal and Squamous Cell Carcinoma__ most frequently occur on the lower eyelid and medial canthus. 4

__Retinoblastoma __  is a malignant embryonal neoplasm arising in the retina during fetal life or early childhood. It occurs unilaterally in 2/3 of patients and bilaterally in 1/3. More than 90% of tumors occur before age 4, Median age is 8 months for patients with bilateral disease and 26 months for unilateral disease. 3  __Optic Glioma__ account for 1% to 5% of intracranial gliomas and 4% of orbital tumors. They occur most frequently in children, with 75%in the irst decade and 90%in the first two decades of life. 4 __Malignant Lymphoma __  of the orbit**-** Primary nonHodgkin's lymphoma of the orbitorbit is a rare disease, accounting for 1% of cases of nonHodgkin's lymphoma and 10% of all orbital tumors. 3

__Lacrimal gland tumors __ <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;"> are rare. <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">4 ||
 * < Etiology: ||< <span style="font-family: Arial,Helvetica,sans-serif;"> __Basal and Squamous Cell Carcinoma__**:** patients with sun exposure and who are immunosuppressed have an increased incidence of these cancers. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">4

__<span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">Malignant Melanoma __ <span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;"> are more common in lightly pigmented skin with an increased risk associated with sun exposure and lighter colored irises. 4 __ <span style="font-family: Arial,Helvetica,sans-serif;">Retinoblastoma __ <span style="font-family: Arial,Helvetica,sans-serif;"><span style="color: #ff00ff; font-family: Arial,Helvetica,sans-serif;">: A family history is present in 10% of patients. It is the classic genetically inhereted pediatric cancer. Results from the loss or mutation of both copies of the RBI gene, located at 13q14. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">3 || The histology of cancers of the eyelid can be basal cell or squamous cell. 2
 * < Signs & <span style="font-family: Arial,Helvetica,sans-serif;">Symptoms: ||< <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">"Retinoblastoma is usually discovered as a result of an abnormal retinal light reflex (White rather than red). This tumor can be noted from a flash photograph or during the pediatrician's routine examination." <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif; vertical-align: super;">2 ||
 * < Diagnostic Procedures: ||< <span style="color: #ff0000; font-family: Arial,Helvetica,sans-serif;">"An opthamologist should also examine both eyes with the child under anesthesia to document multifocality or bilaterality. CT of the brain and orbit can detect unusual cases with extraocular extension or simultaneous supratentorial-pineal lesions(trilateral retinoblastoma). The CSF is assessed by lumbar puncture cytology, and a bone marrow biopsy may be indicated." 2 ||
 * < Histology: ||< <span style="font-family: Arial,Helvetica,sans-serif;"><span style="color: #0000ff; font-family: Georgia,serif;">According to the American Cancer Society Textbook, " Retinoblastoma arises from the primitive neuroectodermal tissue within the nuclear layer of the retina".¹¹ This malignancy is histologically similar to neuroblastoma, medulloblastoma, and pineoblastoma, three other neoplasms of neural origin. Patients with retinoblastoma have been reported to have: multicentric origins, a high frequency of second malignancy, instances of spontaneous regression, and a pattern of inheritance. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">11

<span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Intraocular Melanoma: ---the deep parotid lymph nodes which can be broken down into 2 groups: <span style="color: #008000; font-family: Arial,Helvetica,sans-serif;">---<span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 100%;">the submaxillary lymph nodes which are scattered over the infraorbital region. They are located from the groove between the nose and cheek to the zygomatic arch. ---the buccal lymph nodes which are scattered over the buccinator muscle. <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 88%; vertical-align: super;">2 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 100%;"> Figure 1. Diagram of head and neck lymph nodes. <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 100%; vertical-align: super;">2 <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 100%;"> || Lymphomas of the eye tend to spread to the brain. <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 88%; vertical-align: super;">7 <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> Choroidal melanoma tends to spread to the liver. <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 88%; vertical-align: super;">8 || GX: The grade cannot be assessed. G1: A spindle cell melanoma G2: A mixed cell melanoma G3: An epithelioid melanoma <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 88%; vertical-align: super;">9 <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">
 * <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Spindle cell melanoma (cells are longer and tapered at the ends)
 * <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Epithelioid melanoma (cells are oval-shaped)
 * <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Mixed cell melanoma (both spindle and epithelioid) <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 88%; vertical-align: super;"> 9 <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;"> ||
 * < Lymph Node Drainage: ||< <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Lymph drainage from the eye is:
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">the first group is embedded in the parotid gland. Its superior border is the TMJ, posterior border is the mastoid process, inferior border is the angle of the mandible, and the anterior border is the anterior ramus.
 * <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 110%;">the second group is the subparotid nodes which are "located deep to the gland and lie on the lateral wall of the pharynx."
 * < Metastatic Spread: ||< <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Retinoblastomas tend to spread through the blood to the bone marrow. <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 88%; vertical-align: super;">6 <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">
 * < Grading: ||< <span style="font-family: Arial,Helvetica,sans-serif;"><span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">Intraocular melanoma grading:

<span style="color: #008000; font-family: Arial,Helvetica,sans-serif; font-size: 110%;">Retinoblastoma grading (grouping): Grade 1 (very favorable for preserving or saving the eye) : one or more tumors, smaller than 4 disc diameters (DD), located at or behind the equator Grade 2 (favorable for preserving or saving the eye) : one or more tumor, 4 to 10 DD, located at or behind the equator Grade 3 (doubtful for saving or preserving the eye) : any tumor in front of the equator or one tumor larger than 10 DD behind the equator Grade 4 (unfavorable for preserving or saving the eye) : multiple tumors with some larger than 10 DD or any tumor extending anteriorly to the ora serrata (the front edge of the retina) Grade 5 (very unfavorable for preserving or saving the eye) : tumors involving more than half the eye or vitreous seeding <span style="color: #008000; font-family: Arial,Helvetica,sans-serif;">10 ||
 * < Staging: ||< <span style="color: #0000ff; font-family: Georgia,serif;">The Reese-Ellsworth classification system is the most commonly used for retinoblastoma.

__Group I__ **:** Very favorable: Solitary tumor,<4 optic disc diameter(dd) in size, at or behind the equator Multiple tumors, none > 4 dd in size, all at or behind the equator __Group II__ :<span style="color: #0000ff; font-family: Georgia,serif;"> Favorable: Solitary lesion 4-10 dd in size, at or behind the equator Multiple tumors, none > 4-10 dd in size, behind the equator __Group III__**:** Doubtful: Any lesion anterior to the equator Solitary tumors > 10 dd, behind the equator __Group IV__**:** Unfavorable: Multiple tumors, some > 10 dd Any lesions extending anteriorly to the ora __Group V__ **:** Very unfavorable: Massive tumors involving over half the retina Vitreous seeding <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1 || <span style="color: #0000ff; font-family: Georgia,serif;">2 Gy dose = cataract (single dose). 8 Gy dose = cataract (fractionated dose). 48 Gy dose = corneal injury Doses > 50 Gy result in retinal damage ( retinopathy, retinal atrophy) causing gradual vision loss. Doses > 60 Gy increase risk of optic nerve atrophy. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1 || __Malignant Melanoma__: "The visual outcome of eThe prognostic fators associated with poor visual acuity or vision loss include increased tumor thickness, a proximity of the plaque to loveola of less than 5 mm, and a patient older than 60 years of age." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1 __Retinoblastoma__**:** " Factors that carry a poor prognosis include orbital invasion, involvement of the optic nerve, central nervous system dissemination, and heritable bilateral tumors." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1 __Optic Glioma__**:** They have a long term survival ranging from 80% to 100% with radiation therapy. <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1 __Malignant Lymphoma__**:** " Radiation Therapy alone results in excellent local tumor control ( greater than 85% at 5 years)." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1 ||
 * < Radiation Side Effects: ||< <span style="color: #0000ff; font-family: Georgia,serif;">Radiation therapy side effects include: erythema, depigmentation, atrophy, and telangiectasia (dilated superficial bloodvessels) .Radiation therapy can cause significant morbidity for tumors that exceed 15mm in diameter and 10mm in thickness, so enucleation is preferred. <span style="color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1
 * < Prognosis: ||< __Basal and Squamous Cell Carcinoma__**:** "Overall cure rates of 90% or better are achieves by delivering 45 to 60 Gy using electron or low energy xrays." <span style="color: #ff00ff; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1
 * < Treatments: ||< <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;"><span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">The goal of external-beam irradiation is to provide a homogeneous tumoricidal dose to the tumor with minimal normal tissue toxicity.

__<span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Ocular Malignancies __ <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">1. Basal and Squamous Cell Carcinomas of the Eyelid ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Radiation therapy is the treatment of choice with cure rates of 90% or better ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Low energy photons or electrons are used to give a dose of 45-60 Gy 2. Meibomian Gland Carinoma ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Local recurrences are common ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Radiation therapy or surgery offers acceptable results ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Recommended dose: 60-65 Gy

__<span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Uveal Tumors __ <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">1. Metastatic Tumors of the Posterior Uvea ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Chemotherapy is used. ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">If there is a lack of response from systemic therapy, local treatment should be given with radiation therapy, a dose of 30-35 Gy given to the entire ocular structure ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">If no systemic treatment is given, radiation therapy should be given more aggressively. ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Giving radiation therapy alone dose should meet 45-50 Gy, given with 15-18 MeV (electron therapy) or 4-6 MV (photon therapy) ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Fields should be treated with lateral portals tilted 5-10 degrees posteriorly to avoid dose to the contralateral lens, cornea, and brain 2. Malignant Melanoma of the Posterior Uvea ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Brachytherapy is used for small, growing melanomas in order to preserve vision ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">For increased local control in tumors close to the optic disc a combination of plaque irradiation and laser photocoagulation, transpupillary thermomotherapy, or chemotherapy is used

__<span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Retinal Tumors __ <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">1. Retinoblastoma ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">External beam is used for less advanced retinoblastomas, diffuse vitreous or subretinal seeding, or Group I or II tumors ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">It is necessary to treat the entire retina, whole eye radiation reduces the risk of recurrence significantly ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Field arrangements: single lateral field, single anterior field, or anterior and lateral ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Most techniques are shaped like a “D” and block the anterior half of the field ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Doses given are 40-45 Gy (radiation alone) or 35-40 Gy (radiation + chemotherapy) ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Groups I, II, and III tumors are treated with chemotherapy with a local ophthalmic therapy ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Examples of an ophthalmic therapy are cryotherapy, laser photocoagulation, thermotherapy, or plaque radiation therapy ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Radioactive plaque therapy uses Co-60, iodine 125, iridium192, and ruthenium 109 ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">There is an advantage to using iodine and it is that it is low energy, it gives an adequate dose distribution, and it is easy to shield

__<span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Optic Glioma __ ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Surgery is usually followed by radiation therapy ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Field arrangement is either bilateral temporal set-up or IMRT ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Dose given to children is 45 Gy and 50 Gy to adults

__<span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Orbital Tumors __ <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">1. Rhabdomyosarcoma ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Treatment of choice is a combination of radiation therapy and chemotherapy 2. Malignant Lymphoma of the Orbit ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Treatment of choice is radiation therapy alone ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Dose used is 30-45 Gy 3. Lacrimal Gland Tumors ·<span style="font-family: 'Times New Roman'; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> <span style="font-family: 'Times New Roman','serif'; font-size: 12pt; line-height: 115%;">Treatment of choice is surgery with post-op radiation therapy Dose for post-op radiation is 50-60 Gy (depending on the size of the lesion) <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 80%; vertical-align: super;">1

<span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 130%;">__Orbital Radiation Therapy__ <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 104%; vertical-align: super;">Anterior Field Only || || || || || ||
 * <  ||< Anterior and Lateral Wedged Pair
 * <  ||< Superior Oblique Photon Beams
 * <  ||< 3D Conformal Plan
 * <  ||< Set-up using split beam/IJ Technique. The anterior portion of the beam is blocked.
 * <  ||< Bilateral Set-up
 * < TD5/5: ||< <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">Table provided by Wikibooks. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 88%; vertical-align: super;">5

|| References: <span style="font-family: Arial,Helvetica,sans-serif;"><span style="color: #0000ff; font-family: Georgia,serif;">1. Chao KS, Perez CA, Brady LW. //Radiation Oncology Management Decisions//. second edition. Philadelphia, PA: Lippincott Williams & Wilkins. 2002:177-181. 2. Washington,C.M & Leaver, D.(Eds.).(2004). //Principles and Practice of Radiation Therapy// (Second ed). Pg.881.St. Louis, Missouri; Mosby Inc. <span style="color: #008000; font-family: 'Comic Sans MS',cursive;">389. 3. Cox, JD & Ang, KK. //Radiation Oncology Rationale, Technique, Results.// 8th edition. St. Louis, MS: Mosby, Inc. 2003:287-289,927. 4. Gunderson, LL & Tepper, JE. (Eds.) //Clinical Radiation Oncology//. 2nd edition. Philadelphia, PA: Elsevier, Churchill & Livingstone. 2007: 613-614. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;">5. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 121%;">Radiation Oncology/Toxicity/Emami. Wikibooks. Available at: <span style="font-family: 'Times New Roman',Times,serif; font-size: 110%;">[]. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 121%;">Accessed: January 5, 2010. <span style="color: #008080; font-family: 'Times New Roman',Times,serif; font-size: 110%;"> <span style="color: #008000; font-family: 'Comic Sans MS',cursive;">6. American Cancer Society. //How Is Retinoblastoma Diagnosed//? [] Accessed January 16, 2010. 7. American Cancer Society. //How Are Eye Cancers Staged?// [] Accessed January 16, 2010. 8. Eye Cancer Network. //Overview of the Treatment of Metastatic Melanoma.// [] Accessed January 16, 2010. 9. The ASCO Cancer Foundation: Cancer.net. //Eye Cancer: Staging.// [] Accessed January 16, 2010. 10. American Cancer Society. //How Are Eye Cancers Staged?// <span style="color: #008000; font-family: 'Comic Sans MS',cursive; font-size: 110%;">[] Accessed January 16, 2010. <span style="color: #0000ff; font-family: Georgia,serif;">11. Murphy GP, Lawrence W, Lenhard RE. //American Cancer Society Textbook of Clinical Oncology// .second edition. Atlanta, GA: The American Cancer Society, Inc. 1995; 545.