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Book review |
It may seem strange to introduce a book review with reference to a patriotic British film. The vast majority who watched "Chariots of Fire" were probably unaware that after Harold Abrahams and Eric Liddell, the third and largely unsung hero was Henry Stallard, a medical student at Gonville and Caius College (where Abrahams was also an undergraduate). Although it was his colleagues who won gold medals at the 1924 Paris Olympiad, Stallard won silver but went on to higher achievements in Medicine and Surgery. As Ophthalmic Surgeon to St Bartholomew's and Moorfields Hospital, he pioneered radioactive Cobalt plaque therapy for the treament of ocular tumours, particularly in children. The academic circumstances for this development were appropriately unique: Joseph Rotblatt, originally an atomic physicist who pioneered the use of telecobalt in medicine, was the Professor of Physics and later of Radiobiology, and St Bart's also had two gifted welsh radiotherapists. They were Dr I G Williams, who made paediatric radiotherapy a speciality in its own right, and Professor Arthur Jones, who developed many high precision external beam techniques for eye treatments. In the early 1990s, well into his retirement, Jones recommended to the Medical Research Council that the Clatterbridge Cyclotron should be converted from neutron to proton production specifically for the treatment of choroidal melanomas. Above all, there needed to be a courageous surgeon with an exceptional personality and Stallard certainly provided such a figure – he certainly impressed my parents when I was taken to see him for an opinion at the delicate age of 4. Thus, to a considerable extent, the modern speciality of ocular radiotherapy and oncology was formed in London during the two decades that followed World Was two. The present ocular surgeon at St. Bart's, Mr John Hungerford (also educated at Caius College), performs more plaque treatments per year than Mr Stallard did in his entire career, which exemplifies the growth in this field of oncology.
The eye, for a variety of reasons and particularly because of the extreme sensitivity of the lens to radiation caractogenesis, is arguably the most vulnerable of organs. Many Radiotherapists, Physicists and Radiographers spend a considerable amount of their time and energy attempting to avoid radiation beams exiting through the eye, or to estimate or measure eye dose, in order to minimize the eye dose while irradiating the head, neck and cranial contents.
The book is in some respects a misnomer, for it covers a much wider scope than the pure radiotherapy of ocular pathologies. The role of surgery is particularly well catered for. Ocular Oncology and particularly its radiotherapeutic sub-discipline are usually regarded as an arcane division of Oncology. This may be true in the case of rare ocular melanomas and retinoblastomas: patients with these cancers are referred for treatment to only a few designated centres in the UK, such that many specialists have no experience of such treatments. Such admirable, nationally organized services conform to the highest ideals of The National Health Service and have ensured good practice with a significant research and development component.
There is, of course, more to ocular oncology than the above mentioned two forms of rare cancer and this is well reflected within the book. There are reasonably detailed chapters written by a truly international authorship and which individually cover a substantial range of topics that overlap with other areas of oncology practice. These include the managements of cancers of the eyelids, conjunctiva, lachrymal glands and ducts, thyroid related eye disorders, developmental malformations such as haemangiomas, orbital cavity tumours (the various lymphomas and rhabdomyosarcomas) and optic nerve and tract gliomas. The management of metastatic cancers within the eye and orbit from the common primary cancers, e.g. breast and bronchus, are also discussed. Readers will agree that some of these subjects are not adequately covered in most of the standard radiotherapy textbooks.
As would be expected, the sections on retinoblastomas and uveal tract melanomas are fairly definitive and reflect all the various options of modern management. The indications for the use of surgery, plaque brachytherapy, or protons are very precise and depend on accurate tumour localization and measurement. As well as descriptions of surgical approaches and particle radiotherapy for the posteriorly situated choroidal melanomas, this most recent version of the book contains updated information including the successful approaches to the treatment of anterior uveal melanomas affecting the iris and ciliary tract by surgery and proton radiotherapy at Liverpool and Clatterbridge.
For all the ocular pathologies covered, the merits and problems associated with a complete range of specialized forms of surgery are discussed, including the physical surgical approaches such as radioactive plaques, lasers, photocoagulation, photodynamic treatment, cryotherapy and hyperthermia.
The role of ocular imaging is well represented throughout the book and there is one special chapter devoted to imaging, as well as a detailed special chapter on pathology.
Rather surprisingly situated towards the end of the book there are chapters on ocular radiation tolerance and radiation techniques. There, more appropriately, the comprehensive management of late radiation sequelae is well covered. This is a historically much neglected topic and the chapter is worth reading to appreciate what can be done in the modern era. The only omission appears to be the treatment of macular degenertion, where it is possible that proton radiotherapy may have a place, but this is at present a relatively controversial area of research.
The illustrations are excellent. There are ample photographs of clinical appearances, MR, CT and ultrasound imaging examples, surgical pathology specimens, with many well-produced fundoscopic colour plates. There are radiotherapy treatment set-up photographs, and ample two and three dimensional isodose radiation treatment plans for both conventional and particle radiotherapy. The various indications and techniques for brachytherapy techniques are described and illustrated in sufficient detail for a good understanding of principles and practice, even if one has no experience of the technique.
This book is very informative and is not excessively sized. It should certainly be purchased not only in the departments where there are major ophthalmic commitments, but also in Cancer Centres where there are substantial paediatric, neuro-oncology, head and neck cancer and lymphoma interests. Sections of the book should also be of interest to diagnostic radiologists. General Ophthalmologists should also be aware of the content, in order that they fully appreciate the role of radiotherapy in eye preservation, and the methods in which it is administered to patients. The book will be placed on the Oncology shelves of the BIR Library in Portland Place.
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