Retinoblastoma frontiers with intravenous, intra-arterial, periocular, and intravitreal chemotherapy

Epidemiological profile of retinoblastoma in North India: Implications for primary care and family physicians

Background:

Retinoblastoma is the most common primary intraocular malignancy among children. Despite being curable in early stages, majority of the cases in India present in late stages, when outcomes are very poor.

Objectives:

The aim of this study was to assess the epidemiological profile, clinical characteristics, and treatment practices among retinoblastoma patients in north India.

Materials and Methods:

Data on all patients with retinoblastoma, over a 10-year-time period from 2009 to 2018, who were treated in a tertiary care hospital in north India, were assessed. Data were analyzed to describe the demographic characteristics, clinical features in terms of stage at presentation, and management practices in terms of diagnostic investigations and treatment. The statistical significance for difference in percentages was assessed using Fischer's exact test at a 5% significance level.

Results:

A total of 25 retinoblastoma patients were enlisted, of whom one was excluded as it was adult onset retinoblastoma. The median age at presentation was 3 years, with a male to female ratio of 1:1.4. Bilateral presentation was seen in 16.6% cases. Majority (66.6%) of the patients underwent magnetic resonance imaging of brain and orbit as a part of the diagnostic workup. Intraocular disease was seen in 58.3% patients, whereas 41.6% patients had extraocular disease. Local therapy with vision preservation could be used only in 8.3% patients, whereas 87.5% patients were referred for enucleation. Chemotherapy with combination of vincristine, etoposide, and carboplatin was used extensively both, in neoadjuvant setting (83.3%) and in the adjuvant setting.

Conclusion:

Despite availability of treatment for eye preservation, its utility is limited due to the advanced stage at presentation. Awareness about the disease and its symptoms for early diagnosis, especially with the Mid-Level Health Provider at Health and Wellness Centers, is likely to improve early reporting and treatment and meeting the Vision 2020 goals.

Evaluating primary intra-arterial chemotherapy versus intravenous plus intra-arterial chemotherapy for advanced intraocular retinoblastoma

PURPOSE

Although intra-arterial chemotherapy (IAC) is commonly used for treating intraocular retinoblastoma, it is not a systemic therapy. We aimed to investigate whether the addition of intravenous chemotherapy (IVC) before IAC administration had any effects (whether beneficial or adverse) on patient outcomes.

METHODS

This multicenter retrospective cohort study included 213 patients with advanced intraocular retinoblastoma who received IVC plus IAC (n = 103) or IAC alone (n = 110) between April 2009 and January 2017. Eyes were grouped according to the International Intraocular Retinoblastoma Classification. Kaplan-Meier and Cox regression analyses were performed to compare survival outcomes between the two groups. Moreover, details regarding enucleation were recorded.

RESULTS

The 3-year ocular survival rates were 62% in the IVC plus IAC group and 68% in the IAC group (hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.55-1.43, P = 0.61). Moreover, the corresponding 3-year overall survival rates were 97% and 93%, respectively (HR 1.56, 95% CI 0.41-5.90, P = 0.51), while the 3-year event-free survival rates were 76% and 72%, respectively (HR 0.96, 95% CI 0.56-1.65, P = 0.89).

CONCLUSIONS

Within a 3-year follow-up period, IVC plus IAC produced no additional benefit over primary IAC for treating advanced intraocular retinoblastoma in terms of local tumor control and extending survival. Longer follow-up periods are required to assess long-term efficacy.

Retinopathy in young retinoblastoma patients receiving a chemotherapy treatment: clinical trials and morphometric analysis

Background: This research is to evaluate patients with retinoblastoma, who receive chemotherapy, with enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) to compare the signs of retinopathy.Materials and Methods: A prospective non-randomized trial included 125 eyes of 74 patients at the age of 24 ± 1.6 months with retinoblastoma. All patients underwent an ophthalmoscopic examination and EDI-OCT before therapeutic treatment. The test group consisted of 55 patients, who underwent a course of chemotherapy. Patients were divided into two groups depending on the type of chemotherapy. Group #1 patients received six cycles of systemic intravenous chemotherapy treatment, ophthalmoscopic examination, and EDI-OCT occurred after third cycle and sixth cycle. Group #2 underwent three cycles of IVC chemotherapy treatment, and then local chemotherapy - three cycles of super-selective intra-arterial chemotherapy for exophytic retinoblastoma and 9 procedures of intravitreal (IVT) for endophytic retinoblastoma. Eyes in the control group were affected by eccentric neoplasms but macula and the optic nerve were not damaged.Results: After six cycles of IVC chemotherapy treatment, Group #1 history expanded with atrophy-induced peripapillary nerve fiber layer thinning (33.9%). At three cycle of super-selective intra-arterial chemotherapy, OCT imaging in Group #2 revealed more related symptoms like retinal vascular distention in peritumoral area. After systemic and intravitreal chemotherapy, macular puckers and small hyperreflective dotted foci in the inner retina were tracked. In Group #3 affected by peripheral tumors, the topographic anatomy of the macula was normal prior to therapy.Conclusion: Profound morphometric disturbances that come with combined chemotherapy call for a more careful treatment with methods selected in terms of OCT findings and specific chemotherapy contraindications.

Retinoblastoma regression following intra-arterial chemotherapy to the contralateral eye

Intra-arterial chemotherapy (IAC) has assumed a major role in the management of retinoblastoma. This targeted therapy involves the delivery of chemotherapy directly into the ophthalmic artery, minimizing systemic absorption. We report a case of retinoblastoma regression in the untreated eye following IAC to the contralateral eye.

Efficacy of second-course intra-arterial chemotherapy in children for advanced retinoblastoma recurrence after intra-arterial chemotherapy

Purpose: The present study determined the efficacy and toxicity of second-course intra-arterial chemotherapy (IAC) in advanced retinoblastoma (RB) recurrence in children following failed initial IAC. Materials and Methods: A total of 24 child patients with unilateral or bilateral intra-ocular advanced RB (IIRC Group D and Group E) undergoing second-course IAC treatment after initial intra-arterial chemotherapy between September 2011 and November 2016 were enrolled. Global salvage, ocular adverse events, and systemic adverse events were assessed. Results: Following second-course IAC, 15 (62.5%) showed complete control at 34 months follow-up, while 8 cases (33.3%) failed the treatment and 1 patient with metastatic disease (4.2%) eventually died of brain metastasis after refusing treatment. Ocular adverse events included eyelid edema (n=12), ptosis (n=5), forehead erythema (n-5), enophthalmos (n=3), and cataract (n=2). None of the patients had systemic adverse events, such as stroke or sepsis. Also, no secondary neoplasms and technical complications were observed. Conclusion: Second-course IAC is a potential alternative to enucleation in children with advanced RB, who fail an initial course of IAC. However, patients with advanced RB should be managed at experienced centers in order to consider all the alternatives before enucleation.

Effectiveness of alternative routes of intra-arterial chemotherapy administration for retinoblastoma: Potential for response and complications

OBJECTIVE

Intra-arterial chemotherapy (IAC) is now the first line treatment for selected patients with retinoblastoma (Rb). Typically, IAC is infused following the selective catheterization of the ophthalmic artery (OA) on the affected side. However, in some patients, the OA alone may not provide vascular supply to the tumor, whereas in other instances the efficacy of IAC could be compromised due to the presence of prominent collateral vessels from the external carotid artery (ECA). We report our experience with catheterizing vessels other than the OA for IAC treatment for Rb.

METHODS

After institutional review board approval, a retrospective analysis was conducted of electronic medical records and imaging of our Rb population.

RESULTS

We identified 13 patients who received IAC for Rb treatment. Of these, five patients required alternative methods of chemotherapy delivery other than through the OA, totaling 17 treatments. Two patients needed balloon-assisted occlusion of the ECA, two patients required selective catheterization of the middle meningeal artery, and one patient had no internal carotid artery supply to the choroidal blush, thus the superficial temporal artery provided access for IAC. Total globe salvage rate was 76% and 80% with the alternative route subset.

CONCLUSIONS

Alternatives to the OA may be necessary to deliver IAC for selected cases of Rb. These routes can be safe and effective. However, thorough understanding of the orbital blood supply is essential. Whether these alternative IAC methods result in similar outcomes to OA infusions has not been established.

Co-delivery of miR-181a and melphalan by lipid nanoparticles for treatment of seeded retinoblastoma

Melphalan is an efficient chemotherapeutic agent that is currently used to treat retinoblastoma (Rb); however, the inherent risk of immunogenicity and the hazardous integration of this drug in healthy cells is inevitable. MicroRNAs are short non-coding single-stranded RNAs that affect a vast range of biological processes. Previously, we focused on the regulatory role of miR-181a during cancer development and progression. In this manuscript, 171 nm switchable lipid nanoparticles (LNP) co-delivered melphalan and miR-181a with encapsulation efficiencies of 93%. Encapsulation of melphalan in LNP significantly improved its therapeutic efficiency. Gene analysis shows that miR-181a decreases the expression of anti-proliferative gene MAPK1 and anti-apoptotic gene Bcl-2, but significantly increased the expression of pro-apoptotic gene BAX. Our results suggest that the two agents have a complementary effect in reducing the viability of cultured Rb cells (primary and cell line) and decreasing Rb cell counts in an in-vivo xenograft Rb model in rats. Our results suggest that the proposed co-delivery technique significantly increases the therapeutic impact, allows for lower administration of melphalan, and consequently, could minimize the cytotoxic side-effects of this drug.

Evidence of Tumour Microenvironment and Stromal Cellular Components in Retinoblastoma

BACKGROUND

The tumour microenvironment (TME) consisting of tumour cells and multiple stromal cell types regulate tumour growth, invasion and metastasis. While the concept of TME and presence of stromal cellular components is widely established in cancers, its significance in the paediatric intraocular malignancy, retinoblastoma (RB), remains unknown.

METHODS

The study qualitatively identified the presence of multiple stromal cellular subtypes in RB TME by immunohistochemistry.

RESULTS

Results of the study identified the presence of stromal cell types such as endothelial cells, tumour-associated macrophages, fibroblasts, cancer-associated fibroblasts, retinal astrocytes and glia in RB TME. The extent of stromal marker positivity, however, did not correlate with histopathological features of RB.

CONCLUSIONS

The findings of the study convincingly suggest the presence of a stromal component in RB tumours. The interactions between stromal cells and tumour cells might be of profound importance in RB progression.

VEGF overexpression is associated with optic nerve involvement and differentiation of retinoblastoma: A PRISMA-compliant meta-analysis

BACKGROUND

Vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of cancer. Although numerous studies have investigated the association between VEGF expression and pathogenesis of retinoblastoma, the results remained inconsistent. To illuminate the association, we performed a meta-analysis study.

METHODS

According to the PRISMA guideline, eligible studies were searched in the Medicine, Embase, Web of Science, Chinese National Knowledge Infrastructure, and Wanfang databases. Stata 14.0 software was used to calculate the relevant statistical parameters.

RESULTS

Seventeen studies with 296 controls and 470 patients with retinoblastoma were included from 17 eligible literatures. Overall, significant association between VEGF overexpression and susceptibility of retinoblastoma was observed in Chinese population (odds ratio [OR] = 21.67, 95% confidence interval [CI] = 13.96-33.62). Subgroup analysis based on control sample type showed that VEGF overexpression was significantly associated with the risk of retinoblastoma (Normal retina tissue, OR = 23.97, 95% CI = 9.67-59.42; retinoblastoma adjacent tissue, OR = 20.85, 95% CI = 12.64-34.37). Significant associations of VEGF overexpression with optic nerve involvement and differentiation of retinoblastoma were found (Optic nerve involvement, OR = 6.90, 95% CI = 4.01-11.88; Differentiation, OR = 0.18, 95% CI = 0.12-0.28). In addition, only 1 study was included to analyze the role of VEGF protein expression in the prognosis of retinoblastoma, and the result showed that VEGF expression was significantly associated with the prognosis of retinoblastoma, which should be verified in the future studies.

CONCLUSIONS

Our findings demonstrated that VEGF overexpression was significantly associated with the risk of retinoblastoma. Besides, the results suggested that VEGF overexpression might have a crucial effect on the optic nerve involvement and differentiation of retinoblastoma.

Outcomes of Proton Beam Radiation Therapy for Retinoblastoma With Vitreous Seeds

Vitreous seeds are the most challenging aspect in the management of retinoblastoma. We report the outcomes of treatment with proton beam radiation therapy (PBRT) for retinoblastoma with vitreous seeds in naive or previously treated eyes. In this retrospective case series, we analyzed data of 4 retinoblastoma patients with vitreous seeds who received PBRT at the Proton Therapy Center, National Cancer Center in Korea between June 2007 and August 2017. All 4 eyes treated by PBRT were classified as group D according to the International Classification of Retinoblastoma (ICRB) criteria, and the vitreous seeds, as class 3 (clouds). The tumor and vitreous seeds regressed in 2 eyes, and globe salvage was achieved in these 2 eyes (50%). The post-PBRT ophthalmologic follow-up time of these 2 preserved eyes was 12 and 50 months, respectively. Visual acuity measurements of the successfully treated patients were 20/40 and 20/600. No radiation-associated malignancies were noted. In conclusion, PBRT successfully treated vitreous seeds classified as clouds in half of the cases, and successfully treated patients who retained useful vision. Therefore, PBRT might be a viable treatment option for vitreous seeds in patients with retinoblastoma.

miR‑34a regulates the chemosensitivity of retinoblastoma cells via modulation of MAGE‑A/p53 signaling

The present study aimed to explore the combined role of microRNA (miR)-34a, melanoma antigen-A (MAGE‑A) and p53 in altering the chemosensitivity of retinoblastoma (RB) cells. Human RB and adjacent tumor tissues, as well as human RB cell lines (HXO‑Rb44, SO‑Rb50, Y79 and WERI‑Rb-1) were used. In addition, four chemotherapeutic drugs, including carboplatin, etoposide, Adriamycin and vincristine, were used to treat the cell lines, in order to evaluate the sensitivity of RB cells. Furthermore, miR‑34a expression was detected by reverse transcription-quantitative polymerase chain reaction, and western blotting was implemented to quantify expression levels of MAGE‑A and p53. A luciferase reporter gene assay was used to validate the targeted association between miR‑34a and MAGE‑A. The results indicated that SO‑Rb50 cells exhibited the highest resistance to carboplatin, Adriamycin and vincristine (P<0.05), whereas HXO‑Rb44 cells revealed the highest inhibition rate in response to etoposide (P<0.05) out of the four cell lines. Furthermore, reduced miR‑34a expression and increased MAGE‑A expression significantly elevated the survival rate and viability of SO‑Rb50 cells following drug treatment (all P<0.05). miR‑34a was also demonstrated to directly target MAGE‑A, thereby significantly promoting the viability of RB cells and depressing apoptosis (P<0.05). p53, which was subjected to modulation by miR‑34a and MAGE‑A, also significantly reduced the proliferation rate of RB cells (P<0.05). In conclusion, the miR‑34a/MAGE‑A/p53 axis may be conducive to enhancing the efficacies of chemotherapeutic treatments for RB.

Intra-arterial chemotherapy for unilateral advanced intraocular retinoblastoma: Results and short-term complications

Intra-arterial chemotherapy (IAC) has become an essential technique for the management of advanced intraocular retinoblastoma (RB). In this study, the aim of this article is to describe the clinical results and the short-term complications of IAC performed in our hospital.We retrospectively analyzed patients with newly diagnosed unilateral advanced intraocular (group D or E) RB undergoing IAC from October 2016 to December 2017 in our hospital. We recorded the data including age, gender, cycles of IAC, pathway of arteries approached (ophthalmic artery or middle meningeal artery), ocular and systematic complications, globe salvage.Sixty-one patients underwent IAC performing 189 procedures with a median of 3.1 sessions per eye (range, 1-5 sessions). The overall globe salvage rate is 78.7% (Group D (84.2%), and Group E (69.6%) and followed-up. Short-term ocular complications include eyelid edema (15 cases), ptosis (5 cases), forehead congestion (3 cases), retina hemorrhage (5 cases), choroid atrophy (2 cases), phthisis bulbi (1 case), bradycardia and hypotension during the procedure (7cases), myelosuppressions (6 cases), and nausea and vomiting (5cases).IAC is safe and effective for the treatment of unilateral advanced intraocular RB with a very low complication rate.

Primary Intra-Arterial Chemotherapy for Retinoblastoma in the Intravitreal Chemotherapy Era: Five Years of Experience

Purpose

To report our 5-year experience with intra-arterial chemotherapy (IAC) in the intravitreal chemotherapy (IvitC) era.

Methods

Retrospective review of retinoblastoma treated with primary unilateral IAC in the IvitC era (2012-2017).

Results

There were 34 eyes treated with IAC alone versus 20 eyes treated with IAC plus IvitC for vitreous seeds. IAC (IAC alone vs. IAC plus IvitC) consisted of melphalan (41 vs. 10%) or melphalan plus topotecan (59 vs. 90%, p = 0.03). IvitC consisted of melphalan (60%) or melphalan plus topotecan (40%). Tumor control and globe salvage were achieved in 100% of group B and C eyes without IvitC. Despite more extensive vitreous seeds in the IvitC group (p < 0.01), comparison of IAC alone versus IAC plus IvitC revealed no difference in tumor control for group D (88 vs. 69%, p = 0.36) or group E (67 vs. 100%, p = 0.25) and no difference in globe salvage for group D (88 vs. 69%, p = 0.36) or group E (58 vs. 57%, p = 0.39).

Conclusions

IAC is effective as primary therapy for unilateral group B, C, D, and E retinoblastoma. IvitC is an important adjuvant therapy to achieve comparable globe salvage rates for group D and E eyes with persistent active vitreous seeds.

Intravitreal chemotherapy in retinoblastoma: expanded use beyond intravitreal seeds

BACKGROUND/AIMS

Ophthalmic artery chemosurgery (OAC) has changed the face of retinoblastoma treatment and led to a higher rate of globe salvage. The introduction of intravitreal chemotherapy (IVitC) has further enhanced globe salvage with increased success in treatment of intravitreal seeds. Our group has seen success at treating non-vitreous disease that is refractory to OAC using IVitC. This study was undertaken to quantify and report on this success.

METHODS

A retrospective review was used to identify patients treated with IVitC for indications other than vitreous seeds from two centres. The indication, prior and concurrent treatment, response time and duration of treatment were documented. Kaplan-Meier estimates were used to evaluate ocular and recurrence-free survival. Ocular toxicity was evaluated using the 30 Hz flicker electroretinogram (ERG). Continuous and categorical variables were compared with Student's t-test and χ² test, respectively.

RESULTS

Fifty-six eyes from 52 retinoblastoma patients were identified. There were no disease-related or treatment-related deaths. One patient developed a second primary malignancy (pinealoblastoma) and subsequent leptomeningeal spread. Ninety-eight per cent of the eyes showed clinical regression. Recurrence was seen in 14.3%. Of the recurrences, five occurred in retinal tumours and three in subretinal seeds. The Kaplan-Meier estimated risk of recurrence in all patients treated was 83.5% (95% CI 7.9 to 14.1) at 10 months. The mean change in ERG over treatment course was -17.7 μV.

CONCLUSIONS

Intravitreal chemotherapy is successful for the treatment of subretinal seeds and recurrent retinal tumours and could be considered as adjunctive therapy in globe-sparing treatment of retinoblastoma.

Comparison between intravenous chemotherapy and intra-arterial chemotherapy for retinoblastoma: a meta-analysis

Background

Intravenous chemotherapy (IVC) and intra-arterial chemotherapy (IAC) have become the primary treatments for retinoblastoma; however, some controversy remains over which method is more effective. We conducted a meta-analysis to compare the clinical efficacy of IVC and IAC.

Methods

We systematically searched literature published on PubMed, Embase, and Cochrane Library up to May 2017. Studies containing either IAC or IVC that reported on efficacy were included. The effects estimate was expressed as a pooled rate with 95% confidence interval (CI), using a fixed-effects or random-effects model.

Results

Twenty-six studies were identified which included 1541 eyes (IAC: 11 trials, 445 eyes; IVC: 16 trials, 1096 eyes). The mean follow-up times were 49.4 months (range, 13.0–105.3 months) for IVC and 21.7 months (range, 8.8–38.7 months) for IAC. For the International Classification of Intraocular Retinoblastoma (ICRB) grading, the overall success rate was higher with IAC than with IVC (75.7% [95%CI: 65.7%–83.6%] vs. 69.5% [95%CI: 51.9%–82.8%], P < 0.001). The globe salvage with IAC was higher than with IVC in group D eyes (79.5% [95%CI: 71.8%–85.4%] vs. 55.1% [95%CI: 45.6%–64.2%], P < 0.001), but not in groups B (95.8% [95%CI: 57.5%–99.7%] vs. 82.5% [95%CI: 58.9%–94.0%], P = 0.163), C (91.3% [95%CI: 65.9%–98.3%] vs. 89.0% [95%CI: 69.0%–96.7%], P = 0.212), and E eyes (51.2% [95%CI: 37.0%–65.2%] vs. 43.2% [95%CI: 18.3%–72.1%], P = 0.578). IAC and IVC were not significantly different regarding the recurrence and metastasis rates (15.0% vs. 15.4%, P = 0.148 and 2.7% vs. 0.6%, P = 0.194, respectively). For Reese-Ellsworth (RE) grading, IAC had a higher globe salvage in groups IV (90.9% [95%CI: 56.0%–98.7%] vs. 66.3% [95%CI: 32.4%–89.0%], P = 0.047) and V eyes (83.2% [95%CI: 72.0%–90.5%] vs. 59.9% [95%CI: 43.1%–74.6%], P = 0.003), but not in group I-III eyes (88.6% [95%CI: 58.3%–97.7%] vs. 88.1% [95%CI: 76.6%–94.4%], P = 0.244). The overall success rate was higher in IAC than in IVC (87.1% [95%CI: 78.1%–92.7%] vs. 77.3% [95%CI: 68.1%–84.4%], P = 0.033).

Conclusions

IAC may be superior to IVC for the treatment of retinoblastoma, with a higher overall success rate and higher globe salvage in group D or groups IV and V eyes.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4406-6) contains supplementary material, which is available to authorized users.

Improved procedural safety following protocol changes for selective ophthalmic arterial infusion of chemotherapy for treatment of ocular retinoblastoma

Purpose The aim was to evaluate the impact of protocol changes in selective ophthalmic arterial infusion (SOAI) for treatment of retinoblastoma (Rb). Methods A retrospective review was completed of 35 patients with Rb who were treated with SOAI between March 2010 and January 2017. Treatment details were tabulated for each SOAI session. SOAI protocol was changed in June 2015, and differences before and after this change were evaluated using two-tail chi-square tests and independent sample t-tests to note any differences in technical complications, need for enucleation, and other outcome variables Results 125 SOAI sessions occurred. No technical complications occurred during the study. Two complications (1.6%) occurred in the postoperative setting. Both complications occurred prior to the change in protocol. Comparing the complication rates between the two protocols showed no significant difference (2.2% versus 0.0%; p = 0.505); 29 of 43 (67.4%) eyes had their vision preserved overall. Conclusions SOAI is an effective treatment for Rb. The refined protocol described herein was associated with fewer complications.

SYK-targeted dendritic cell-mediated cytotoxic T lymphocytes enhance the effect of immunotherapy on retinoblastoma

PURPOSE

Retinoblastoma (RB) is the most common primary intraocular tumor in children. Chemotherapy is currently the main method of RB treatment. Unfortunately, RB often becomes chemoresistant and turns lethal. Here, we used in vitro cell immunotherapy to explore whether adoptive immunotherapy could be used as a potential treatment for RB. We focused on spleen tyrosine kinase (SYK), which is significantly upregulated in RB cells and serves as a marker for RB cells.

METHODS

Using lentiviruses, we genetically modified dendritic cells (DCs) to express and present the SYK peptide antigen to cytotoxic T lymphocytes (CTLs) in vitro. We used SYK-negative cell lines (MDA-MB-231, MCF-10A, and hTERT-RPE1) and SYK-positive cell lines (MCF-7 and RB-Y79) to evaluate the specificity and cytotoxicity of DC presented CTLs using FACS, live-cell imaging, and RNA interference.

RESULTS

The cytotoxicity of CTLs induced by SYK-overexpressing DCs (SYK-DC-CTLs) was enhanced more than three times in SYK-positive cell lines compared with SYK-negative cell lines. DCs primed with SYK could drive CTL cytotoxicity against SYK-positive cell lines but not against SYK-negative cell lines. Moreover, SYK-silenced RB-Y79 cells successfully evaded the cytotoxic attack from SYK-DC-CTLs. However, SYK-DC-CTLs could target SYK overexpressed hTERT-RPE1 cells, suggesting that SYK is a specific antigen for RB. Furthermore, SYK-DC-CTL exhibited specific cytotoxicity against carboplatin-resistant RB-Y79 cells in vitro.

CONCLUSIONS

Our data showed that SYK could be a potential immunotherapy target mediated by DCs. We propose SYK as a candidate target for treatment of chemoresistant RB.

Retinoblastoma

Retinoblastoma represents 3% of all childhood cancers, and is the most common intraocular malignancy of childhood. It is fatal, if untreated. White eye reflex, also known as leukocoria, is the commonest sign, followed by strabismus. The pediatricians have a very important role to play in the diagnosis of this relatively rare, but easily detectable tumor. Early diagnosis yields better results. The management of retinoblastoma has gradually evolved over the past few decades, with an aim to not only preserve life and eye, but also optimize residual vision. The treatment of retinoblastoma is multimodal, with chemotherapy, focal treatment including trans-pupillary thermotherapy, cryotherapy and laser photocoagulation, radiation therapy and surgery, all playing a vital role. Intravenous chemotherapy has been the mainstay of treatment for the past two decades, and still continues to be the most extensively used eye-saving modality of treatment. Periocular and intravitreal chemotherapy have specific indications in the management of retinoblastoma. Intra-arterial chemotherapy has emerged as a promising alternative for advanced and refractory retinoblastoma, both as a primary and secondary therapy. Recent advances in genetics of retinoblastoma have also helped in improving the overall clinical management of this malignancy.

Potential of Aqueous Humor as a Surrogate Tumor Biopsy for Retinoblastoma

Importance

Retinoblastoma (Rb) is one of the first tumors to have a known genetic etiology. However, because biopsy of this tumor is contraindicated, it has not been possible to define the effects of secondary genetic changes on the disease course.

Objective

To investigate whether the aqueous humor (AH) of Rb eyes has sufficient tumor-derived DNA to perform genetic analysis of the tumor, including DNA copy number alterations.

Design, Setting, and Participants

This investigation was a case series study at a tertiary care hospital (Children's Hospital Los Angeles) with a large Rb treatment center. Cell-free DNA (cfDNA) was isolated from 6 AH samples from 3 children with Rb, including 2 after primary enucleation and 1 undergoing multiple intravitreous injections of melphalan for vitreous seeding. Samples were taken between December 2014 and September 2015.

Main Outcomes and Measures

Measurable levels of nucleic acids in the AH and identification of tumor-derived DNA copy number variation in the AH. The AH was analyzed for DNA, RNA, and micro-RNA using Qubit high-sensitivity kits. Cell-free DNA was isolated from the AH, and sequencing library protocols were optimized. Shallow whole-genome sequencing was performed on an Illumina platform, followed by genome-wide chromosomal copy number variation profiling to assess the presence of tumor DNA fractions in the AH cfDNA of the 3 patients. One child's cfDNA from the AH and tumor DNA were subjected to Sanger sequencing to isolate the RB1 mutation.

Results

Six AH samples were obtained from 3 Rb eyes in 3 children (2 male and 1 female; diagnosed at ages 7, 20, and 28 months). A corroborative pattern between the chromosomal copy number variation profiles of the AH cfDNA and tumor-derived DNA from the enucleated samples was identified. In addition, a nonsense RB1 mutation (Lys→STOP) from 1 child was also identified from the AH samples obtained during intravitreous injection of melphalan, which matched the tumor sample postsecondary enucleation. Sanger sequencing of the AH cfDNA and tumor DNA with polymerase chain reaction primers targeting RB1 gene c.1075A demonstrated this same RB1 mutation.

Conclusions and Relevance

In this study evaluating nucleic acids in the AH from Rb eyes undergoing salvage therapy with intravitreous injection of melphalan, the results suggest that the AH can serve as a surrogate tumor biopsy when Rb tumor tissue is not available. This novel method will allow for analyses of tumor-derived DNA in Rb eyes undergoing salvage therapy that have not been enucleated.

Metastatic deaths in retinoblastoma patients treated with intraarterial chemotherapy (ophthalmic artery chemosurgery) worldwide

BACKGROUND

Ophthalmic artery chemosurgery [OAC, intra-arterial chemotherapy (IAC)] was introduced in 2006 as treatment modality for intraocular retinoblastoma. The purpose of this commentary is to retrospectively review the incidence of metastatic deaths in retinoblastoma patients treated with OAC worldwide over a 10 year period. Retrospective data regarding metastatic deaths was collected from six international retinoblastoma centers (New York City USA, Philadelphia USA, Sao Paulo Brazil, Siena Italy, Lausanne Switzerland and Buenos Aires Argentina). All retinoblastoma patients from these centers (naive and recurrent, unilateral and bilateral) treated with OAC/IAC since 2006 have been included in this study. Data regarding number of patients, number of OAC/IAC infusions, number unilateral and bilateral, number treated for naive disease or salvage and number of metastatic deaths have been assessed. Over a 10-year period of time 1139 patients received OAC/IAC for 4396 infusions. At last follow-up there were only three metastatic deaths (all treated in Buenos Aires).

CONCLUSION

The current survey assessed the recorded risk of metastatic deaths in six retinoblastoma centers worldwide in children with retinoblastoma (unilateral or bilateral) treated with OAC/IAC as primary or secondary therapy. Overall, the observed risk for metastatic deaths from retinoblastoma was <1% in OAC/IAC treated children.

Characterization and Molecular Mechanism of Peptide-Conjugated Gold Nanoparticle Inhibiting p53-HDM2 Interaction in Retinoblastoma

Inhibition of the interaction between p53 and HDM2 is an effective therapeutic strategy in cancers that harbor a wild-type p53 protein such as retinoblastoma (RB). Nanoparticle-based delivery of therapeutic molecules has been shown to be advantageous in localized delivery, including to the eye, by overcoming ocular barriers. In this study, we utilized biocompatible gold nanoparticles (GNPs) to deliver anti-HDM2 peptide to RB cells. Characterization studies suggested that GNP-HDM2 was stable in biologically relevant solvents and had optimal cellular internalization capability, the primary requirement of any therapeutic molecule. GNP-HDM2 treatment in RB cells in vitro suggested that they function by arresting RB cells at the G2M phase of the cell cycle and initiating apoptosis. Analysis of molecular changes in GNP-HDM2-treated cells by qRT-PCR and western blotting revealed that the p53 protein was upregulated; however, transactivation of its downstream targets was minimal, except for the PUMA-BCl2 and Bax axis. Global gene expression and in silico bioinformatic analysis of GNP-HDM2-treated cells suggested that upregulation of p53 might presumptively mediate apoptosis through the induction of p53-inducible miRNAs.

Dermal-fat graft for anophthalmic socket in children enucleated for retinoblastoma

Retinoblastoma is the most frequent intraocular tumour in childhood. The definitive treatment is enucleation. The management of the anophthalmic socket consists in the use of a plastic implant. The problem is that they are expensive and they usually extrude. The use of dermal-fat grafts minimises the hemi-facial hypoplasia. They usually grow with the face, and help to expand the orbital bones, thus avoiding the psychological and physical consequences.

OBJECTIVE

To determine if there is hemi-facial hypoplasia, using MRI images after the use of a dermal-fat implant in patients enucleated for RB.

METHOD

The study included patients enucleated for RB in which a dermal-fat implant was used and MRI images were taken in the period between June 2010 and December 2012. Facial growth and cosmesis was measured.

RESULTS

The study included 12 patients, aged between 6 to 41 months. After 24 months of follow up, none of them developed hemifacial hypoplasia. All had a good cosmesis with the prosthesis. There were no complications after the surgery.

CONCLUSIONS

The use of dermal-fat implant is a good option for the anophthalmic socket in patients with RB after enucleation.

Systemic neoadjuvant chemotherapy for Group B intraocular retinoblastoma (ARET0331): A report from the Children's Oncology Group

PURPOSE

To evaluate a chemoreduction regimen using systemic vincristine and carboplatin (VC) and local ophthalmic therapies to avoid external-beam radiotherapy (EBRT) or enucleation in patients with Group B intraocular retinoblastoma.

PATIENTS AND METHODS

Twenty-one patients (25 eyes) were treated with six cycles of VC, accompanied by local ophthalmic therapies after cycle 1. The primary study objective was to determine the 2-year event-free survival (EFS) where an event was defined as the use of systemic chemotherapy in addition to vincristine or carboplatin, EBRT, and/or enucleation.

RESULTS

All patients had tumor regression after the first cycle of VC and only two patients had progression during therapy. There were seven treatment failures within 2 years of study enrollment, resulting in 2-year EFS of 65% and early study closure in accordance with the statistical design. The 2-year cumulative incidence of enucleation was 15%; for external beam radiation therapy, it was 10%; and for chemotherapy to control progressive disease, it was 10%. All patients sustaining a treatment failure were salvaged with additional therapy.

CONCLUSIONS

For the majority of patients with Group B intraocular retinoblastoma, chemoreduction with VC, without etoposide, in conjunction with local therapy provides excellent opportunity for ocular salvage. Local therapy given with every chemotherapy cycle and incorporation of etoposide may provide improved ocular salvage rates. Central review of group at diagnosis is critical in assigning appropriate therapies.

Clinical Significance of Optic Nerve Enhancement on Magnetic Resonance Imaging in Enucleated Retinoblastoma Patients

PURPOSE

The aim of this 8-year retrospective review was to determine the clinical significance of gadolinium-enhanced magnetic resonance imaging (MRI) findings in retinoblastoma patients after enucleation, particularly the presence of abnormal contrast enhancement of the transected optic nerve.

DESIGN

Retrospective chart review.

SUBJECTS

A review was done on 88 patients with retinoblastoma undergoing 90 enucleations between January 2008 and December 2015.

METHODS

These patients underwent 233 MRI scans: 90 preoperative and 143 postoperative that were included for review.

MAIN OUTCOME MEASURE

The primary outcome measure assessed was abnormal MRI findings in the preoperative and postoperative MRI scans, specifically enhancement of the optic nerve and correlations between abnormal MRI findings and clinical outcomes for the 88 patients.

RESULTS

On the preoperative MRI, 4 optic nerves out of 90 scans showed positive enhancement. Fifty orbits had ≥1 postoperative MRI. Overall, 41 of 50 orbits (82%) of enucleated patients demonstrated postoperative contrast enhancement on MRI after enucleation, at a mean interval of 10 months after surgery. The percentage of MRI scans with optic nerve enhancement was 77% from 0 to 6 months after enucleation and 68% at >24 months after surgery. Postenucleation optic nerve enhancement did not correlate with preoperative optic nerve enhancement, chemotherapy administration, or the presence of optic nerve invasion on histopathology. No child required an orbital biopsy. None of the 88 patients were found to have subsequent orbital or metastatic disease at the last clinical follow-up visit (average, 29 months; range, 1-71).

CONCLUSION

Optic nerve contrast enhancement on follow-up MRI after enucleation for retinoblastoma seems to be a common, benign radiographic finding; none of the patients in this series developed extraocular tumor relapse. The presence of postenucleation enhancement on MRI did not correlate with preoperative chemotherapy or the presence of optic nerve invasion on histopathology. Based on our findings, intervention for isolated optic nerve enhancement on MRI is not indicated in the absence of other abnormal clinical or radiographic signs. A prospective trial with a validated radiographic grading system would be helpful to clarify the MRI features to differentiate orbital recurrence from benign postoperative enhancement.

Vitreous Seeds in Retinoblastoma: Clinicopathologic Classification and Correlation

PURPOSE

A recent classification scheme for retinoblastoma vitreous seeds has shown promise in predicting treatment response. For the first time, we correlate this clinical classification scheme with its histopathologic features.

DESIGN

Retrospective review.

PARTICIPANTS

Enucleated eyes received at the pathology department of the Retinoblastoma Center of Houston from 2010 to 2015.

METHODS

Macroscopic photographs of the enucleated eyes of patients with retinoblastoma were analyzed to select those with vitreous seeds. Cases with adequate material for clinicopathologic correlation were selected for further analysis, and clinical photographs were reviewed. Routine histopathologic slides were reviewed and compared with the clinical and macroscopic photographs. Seeds were classified as type 1 ("dust"), type 2 ("sphere"), or type 3 ("cloud"). To confirm the presence of macrophages, CD68 immunohistochemical staining was used. Synaptophysin was used to stain retinoblastoma cells.

MAIN OUTCOME MEASURES

To correlate clinical vitreous seed type with histopathologic features.

RESULTS

A total of 14 eyes with adequate amounts of tumor seeds along with clinical and macroscopic photographic correlation were selected from a total of 138 eyes reviewed. Type 1 seeds consisted of individual viable tumor cells and scattered macrophages. Type 2 seeds consisted of 2 submorphologies: spheres with viable cells throughout and spheres with an outer rim of viable cells but necrotic cells centrally. Type 3 seeds were composed of more than 90% necrotic material admixed with few macrophages and viable cells at their outer rim. Untreated (8/14) and previously treated (6/14) eyes showed similar histopathologic features for each type of seeds. Treated eyes had more type 1 and 3 seeds.

CONCLUSIONS

We provide the first histopathologic correlation of the clinical classification scheme for vitreous seeds in retinoblastoma. "Dust" is formed by scattered single cells alternating with macrophages. "Spheres" with translucent centers contain multiple layers of viable tumor cells that shed single cells and may be more clinically aggressive. "Cloud" seeds are mostly composed of necrotic material, explaining their lack of therapeutic response. Pretreated eyes showed tumor seeds morphologically similar to untreated eyes. Knowledge of the underlying histopathology of vitreous seed types is a fundamental component of classification and may aid in understanding clinical response to treatment.

Detection of Minimally Visible Recurrent Retinoblastoma by Hand-held Spectral-Domain Optical Coherence Tomography

A 2-month-old male infant with bilateral familial retinoblastoma was treated with intravenous chemotherapy and focal adjuvant therapy. At 5 months of follow-up, fundus examination and ultrasonography disclosed no recurrence; however, hand-held spectral-domain optical coherence tomography (SD-OCT) demonstrated subclinical recurrence within a previous regression scar. Subsequent treatment led to flat scar. Hand-held SD-OCT can be a useful tool for detection of subclinical recurrent retinoblastoma. [J Pediatr Ophthalmol Strabismus. 2017;54:e6-e8.].

The American Society of Retina Specialists 2016 Founders Award Lecture

Purpose:

To review the current state of the art of retinal tumors with respect to clinical features, imaging, and management.

Methods:

Review of published literature and personal experience from an ocular oncology service.

Results:

There are several tumors that arise from the sensory retina including those of glial origin (astrocytic hamartoma, acquired astrocytoma, and solitary circumscribed retinal astrocytic proliferation), neural origin (retinoblastoma), and vascular origin (hemangioblastoma, cavernous hemangioma, racemose hemangioma, and vasoproliferative tumor). Most retinal tumors are benign with the exception of retinoblastoma and retinal metastasis. Some retinal tumors are associated with systemic oculoneurocutaneous syndromes such as tuberous sclerosis complex (TSC), 13q deletion syndrome, Von Hippel–Lindau disease, and systemic cavernous and racemose hemangioma syndromes with ocular, cutaneous, neurologic, and other findings. Regarding management, recent data indicate that retinal astrocytic hamartoma and retinal achromic patch are key to the diagnosis of TSC and imply greater risk for brain and kidney tumors. Some children with TSC respond to mammalian target of rapamycin inhibitors, controlling brain, kidney, and eye tumors. Children with retinoblastoma are all screened genetically, and systemic evaluation is provided for detection of metastasis and secondary-related tumors. Newer chemotherapy regimens by intravenous or intra-arterial routes have revolutionized retinoblastoma control. Retinal vascular tumors are uncommon but can have serious systemic implications. Therefore, imaging of the brain for related cerebellar hemangioblastoma, midbrain racemose hemangioma, or multifocal cavernomas is performed. Genetic testing for each disease can be revealing.

Conclusions:

Retinal tumors are often benign, can be recognized by clinical and imaging features, and can be associated with important systemic syndromes.

Intravitreal chemotherapy in the management of vitreous disease in retinoblastoma

PURPOSE

To evaluate the therapeutic outcome of intravitreal melphalan injection in the management of vitreous disease in patients with retinoblastoma. We particularly aimed to assess whether higher melphalan dose with lower number of injections was more effective and associated with fewer side effects.

METHODS

This retrospective, interventional, noncomparative, and nonrandomized study included 39 eyes of 37 patients. Vitreous seeds were classified as dust, sphere, and cloud types. Intravitreal injections were performed through pars plana free of any visible tumor using 30-G needle. Response of the seeds (disappearance, conversion into inactive debris, or progression) and enucleation rate were determined as outcome measures.

RESULTS

All patients previously received systemic or intra-arterial chemotherapy. Vitreous seeding was primary in 54% of eyes and secondary in 46% of eyes. Vitreous seeds were classified as dust in 9 (23.1%) eyes, sphere in 24 (61.5%) eyes, and cloud in 6 (15.4%) eyes. Melphalan dose varied between 20 and 40 µg and 20 (51.3%) eyes received >30 µg. The total number of injections was 70 (range 1-5, mean 1.8 per eye). Various types of regression were obtained in 27 (69.2%) eyes. Sphere-type seeds were the most responsive to melphalan. Nonresponse and disease progression were noted in 12 (30.8%) eyes. After a mean follow-up of 11.8 months, 17 (44%) eyes were enucleated. Vitreous hemorrhage (18%) and retinal pigment epithelial alterations (8%) were the most common side effects.

CONCLUSIONS

Intravitreal melphalan at 30-40 µg in 1 or 2 injections proved effective in 69.2% of eyes with vitreous disease.

INTRAVITREOUS CHEMOTHERAPY FOR ACTIVE VITREOUS SEEDING FROM RETINOBLASTOMA: Outcomes After 192 Consecutive Injections. The 2015 Howard Naquin Lecture

PURPOSE

To investigate on the safety and efficacy of intravitreous chemotherapy for retinoblastoma seeding in a relatively large cohort and provide information on the necessary number of injections and long-term control.

METHODS

Retrospective interventional case series of 40 consecutive eyes with viable vitreous seeding after standard treatment of retinoblastoma. All eyes received intravitreal melphalan injection (20-30 μg) and additional topotecan (20 μg) as needed using the trans pars plana route with triple freeze-thaw cryotherapy at needle withdrawal for prevention of extraocular seeding for planned six cycles.

RESULTS

The mean patient age at presentation was 36 months, and interval to need for vitreous injection was 14 months. Viable vitreous (n = 40 eyes) and additional subretinal (n = 2 eyes) seeds were documented. There was a total of 192 injections using melphalan (n = 148) and/or topotecan (n = 44) with mean number of injections per eye of melphalan at 4 (median, 4; range, 1-6) and topotecan at 3 (median, 3; range, 1-5). Fewer than six planned melphalan injections (n = 31 cases, 78%) were necessary because of rapid and complete vitreous seed control (n = 30 eyes) or melphalan allergy (n = 1 eye). Fewer than six planned topotecan injections (n = 14 cases, 100%) were necessary because of rapid and complete vitreous seed control in all cases. At median 3-year follow-up, therapeutic success with continued seed regression was observed in all 40 eyes (100%). Globe salvage was attained in 35 cases (88%), and enucleation (n = 5) was necessary for extensive recurrent subretinal seeds (n = 2), neovascular glaucoma with vitreous hemorrhage (n = 2), and hemorrhagic retinal necrosis (n = 1). Side effects included focal retinal pigment epithelial mottling at the site of injection (n = 12), minor focal paraxial lens opacity (not requiring cataract surgery) (n = 11), transient focal vitreous hemorrhage (n = 5), transient hypotony (n = 3), transient retinal hemorrhage (n = 2), optic disc edema (n = 1), and hemorrhagic retinal necrosis (n = 1). There was no case of endophthalmitis, extraocular tumor extension, metastasis, or death.

CONCLUSION

Intravitreal melphalan and/or topotecan injection for retinoblastoma vitreous seeding provides lasting tumor control at 3 years with approximately 4 injections.

Intra-arterial chemotherapy for retinoblastoma: First Indian report

Aim:

To describe treatment outcomes and complications of selective intra-arterial chemotherapy (IAC) for retinoblastoma (RB) in Indian eyes.

Materials and Methods:

Single center, retrospective interventional case series of 6 eyes with RB who underwent IAC using Melphalan (3 mg/5 mg/7.5 mg) and topetecan (1 mg) (n = 4) or melphalan (3 mg/5 mg/7.5 mg) alone (n = 2) between December 2013 and June 2014. In all, 17 IAC procedures were performed using selective ophthalmic artery cannulation. Treatment outcomes were evaluated in terms of tumor control, vitreous and subretinal seeds control and globe salvage rates.

Results:

IAC was employed as primary (n = 1) or secondary (n = 5) modality of treatment. Each eye received mean 3 IAC sessions (median: 3; range: 1-4 sessions). Eyes were classified according to international classification of RB as Group B (n = 1), C (n = 1), D (n = 2) and E (n = 2). Following IAC, complete regression of the main tumor was seen in 3 cases (50%), partial regression in 2 (33%), while 1 case (15%) showed no response. Of 4 eyes with subretinal seeds, 1 (25%) eye had complete regression while 3 (75%) eyes had partial regression. Of 5 eyes with vitreous seeds, 2 (40%) eyes had complete regression while 3 (60%) eyes had a partial response. Globe salvage was achieved in 5 of 6 eyes (83%). Diffuse choroidal atrophy and vitreous hemorrhage were observed in 1 (17%) eye, each. No hematologic toxicity or cerebro-vascular events were observed. Mean follow-up period was 5.5 months (median: 6 months, range: 1-6 months).

Conclusion:

IAC is an effective therapy for globe preservation in eyes with RB. Larger studies with longer follow-up are required to validate these results.

Retinoblastoma: achieving new standards with methods of chemotherapy

The management of retinoblastoma (RB) has dramatically changed over the past two decades from previous radiotherapy methods to current chemotherapy strategies. RB is a remarkably chemotherapy-sensitive tumor. Chemotherapy is currently used as a first-line approach for children with this malignancy and can be delivered by intravenous, intra-arterial, periocular, and intravitreal routes. The choice of route for chemotherapy administration depends upon the tumor laterality and tumor staging. Intravenous chemotherapy (IVC) is used most often in bilateral cases, orbital RB, and as an adjuvant treatment in high-risk RB. Intra-arterial chemotherapy (IAC) is used in cases with group C or D RB and selected cases of group E tumor. Periocular chemotherapy is used as an adjunct treatment in eyes with group D and E RB and those with persistent/recurrent vitreous seeds. Intravitreal chemotherapy is reserved for eyes with persistent/recurrent vitreous seeds. In this review, we describe the various forms of chemotherapy used in the management of RB. A database search was performed on PubMed, using the terms “RB,” and “treatment,” “chemotherapy,” “systemic chemotherapy,” “IVC,” “IAC,” “periocular chemotherapy,” or “intravitreal chemotherapy.” Relevant English language articles were extracted, reviewed, and referenced appropriately.

The role of intravitreal chemotherapy for retinoblastoma

Targeted therapy in retinoblastoma (RB) is widely accepted as the current management tool with an aim of increasing drug availability at the tumor location. Inevitably the effect is several times higher compared to systemic delivery of chemotherapeutic drugs and carries less systemic toxicity. Despite tremendous advancement in saving life, eye salvage in advanced RB especially with active vitreous seeds remains a challenge. The hypoxic environment of the vitreous and reduced vitreous concentration of the drugs delivered makes these tumor seeds resistant to chemotherapy. Direct delivery of chemotherapeutic drugs into the vitreous cavity aids to overcome these challenges and is progressively being accepted worldwide. However, intraocular procedure in RB was abandoned due to high risk of extraocular tumor dissemination. Recently, the forbidden therapeutic technique was re-explored and modified for safe use. Although eye salvage rate has tremendously improved after intravitreal chemotherapy (IVitC), retinal toxicity, and vision salvage are yet to be validated. In our preliminary report of intravitreal melphalan in 11 eyes, we reported 100% eye salvage and 0% recurrence with an extended 15 months mean follow-up. In this review, we analyzed published reports on IVitC in RB via PubMed, Medline, and conference proceedings citation index, electronic database search, without language restriction that included case series and reports of humans and experimental animal eyes with RB receiving IVitC.

Erlotinib has tumor inhibitory effect in human retinoblastoma cells

AIM

In this study, we explored the effect of erlotinib on the development of retinoblastoma (RB) cells both in vitro and in vivo.

METHOD

RB cell lines, Y79 and WERI cells were treated with various concentrations of erlotinib in vitro to assess their cytotoxic profiles. In vitro proliferation, cell-cycle transition and migration were compared between RB cells treated with erlotinib and cells without erlotinib treatment. In in vivo tumorigenicity assay, mice were injected with Y79 cells and orally fed with erlotinib for 28days. The effect of erlotinib on in vivo tumor grafts was then assessed. Western blot analysis on EGFR, ERK, AKT proteins and their phosphorylated proteins was also performed to assess molecular signaling pathways of associated with erlotinib in RB cells.

RESULTS

In vitro erlotinib treatment induced cytotoxicity in Y79 and WERI cells in dose-dependent manner. While Y79 and WERI cells were treated with erlotinib close to EC₅₀ concentrations for 3days, RB proliferation, cell-cycle transition and migration were all significantly inhibited. In in vivo tumorigenicity assay, oral induction of erlotinib also dramatically reduced the growth of Y79 tumor grafts. Western blot demonstrated that, in in vitro RB cells, erlotinib did not alter the protein expression levels of EGFR, ERK or AKT, but significantly reduced the expressions of phosphorylated EGFR, ERK and AKT proteins.

CONCLUSION

Erlotinib was shown to have tumor suppressive effect on RB growth in vitro and in vivo, possibly through the inhibition on EGFR, ERG/AKT signaling pathways.

Clinical significance of high levels of survivin and transforming growth factor beta-1 proteins in aqueous humor and serum of retinoblastoma patients

PURPOSE

To evaluate the diagnostic and prognostic values of survivin and transforming growth factor beta-1 (TGF-B1) expression in aqueous humor and serum of retinoblastoma (RB) in comparison to the conventional RB marker lactate dehydrogenase (LDH) and to elucidate a possible correlation between them and the clinicopathological features of the disease.

METHODS

This prospective, comparative study included 88 newly diagnosed children with RB and 80 age-matched controls with ophthalmic conditions other than tumors prepared for intraocular surgeries. Concentrations of survivin, TGF-B1, and LDH were measured in serum and aqueous humor before and 6 months after completion of therapy.

RESULTS

High serum and aqueous humor concentrations of the three proteins were detected in RB patients before treatment compared to the control group (P < 0.01), with a significant reduction of serum concentrations after treatment (P < 0.01). For the highest sensitivity and specificity, the optimal cutoff values of serum and aqueous survivin were 12.9 pg/ml and 25.2 pg/mg, with a significant positive correlation between aqueous survivin and RB staging and presence of optic nerve infiltration (r = 0.43, P = 0.04); the best cutoff values of serum and aqueous TGF-B1, 370.7 pg/ml and 39.8 pg/mg, with a significant positive correlation between aqueous TGF-B1 and poor differentiation of the tumor (r = 0.69, P = 0.001).

CONCLUSIONS

The high sensitivity, specificity, and accuracy of serum and aqueous humor survivin and TGF-B1 proteins make them promising markers for early detection and follow-up of RB patients.

Retinoblastoma: might photodynamic therapy be an option?

Retinoblastoma is a tumor that mainly affects children under 5 years, all over the world. The origin of these tumors is related with mutations in the RB1 gene, which may result from genetic alterations in cells of the germ line or in retinal somatic cells. In developing countries, the number of retinoblastoma-related deaths is higher due to less access to treatment, unlike what happens in developed countries where survival rates are higher. However, treatments such as chemotherapy and radiotherapy, although quite effective in treating this type of cancer, do not avoid high indices of mortality due to secondary malignances which are quite frequent in these patients. Additionally, treatments such as cryotherapy, thermotherapy, thermochemotherapy, or brachytherapy represent other options for retinoblastoma. When all these approaches fail, enucleation is the last option. Photodynamic therapy might be considered as an alternative, particularly because of its non-mutagenic character. Photodynamic therapy is a treatment modality based on the administration of photosensitizing molecules that only upon irradiation of the tumor with a light source of appropriate wavelength are activated, triggering its antitumor action. This activity may be not only due to direct damage to tumor cells but also due to damage caused to the blood vessels responsible for the vascular supply of the tumor. Over the past decades, several in vitro and in vivo studies were conducted to assess the effectiveness of photodynamic therapy in the treatment of retinoblastoma, and very promising results were achieved.

Retinoblastoma Control With Primary Intra-arterial Chemotherapy: Outcomes Before and During the Intravitreal Chemotherapy Era

PURPOSE

To compare outcomes of intra-arterial chemotherapy for retinoblastoma as primary therapy before (Era I) and during (Era II) the intravitreal chemotherapy era.

METHODS

In this retrospective interventional case series at a tertiary referral center, 66 eyes of 66 patients with untreated unilateral retinoblastoma were used. intraarterial chemotherapy into the ophthalmic artery under fluoroscopic guidance was performed using melphalan in every case, with additional topotecan as necessary. Intravitreal chemotherapy using melphalan and/or topotecan was employed as needed for active vitreous seeding. Globe salvage was measured based on the International Classification of Retinoblastoma (ICRB) during two eras.

RESULTS

The two eras encompassed 2008 to 2012 (intraarterial chemotherapy alone, Era I) and 2012 to 2015 (intraarterial chemotherapy plus intravitreal chemotherapy, Era II). Over this period, there were 66 patients with unilateral untreated retinoblastoma treated with primary intra-arterial chemotherapy. A comparison of features (Era I vs Era II) revealed no significant difference in mean patient age (24 vs 24 months), ICRB groups, mean largest tumor diameter (19 vs 17 mm), mean largest tumor thickness (10 vs 10 mm), vitreous seed presence (56% vs 59%), subretinal seed presence (67% vs 62%), retinal detachment (70% vs 66%), or vitreous hemorrhage (0% vs 5%). There was no significant difference in mean number of intra-arterial chemotherapy cycles (3 vs 3.1) or intraarterial chemotherapy dosages. Following therapy, there was a significant difference (Era I vs Era II) in the need for enucleation overall (44% vs 15%, P = .012), especially for group E eyes (75% vs 27%, P = .039). Four of the eyes that initiated therapy in Era I later required intravitreal chemotherapy during Era II. The enucleation rate was 0% for groups B and C in both eras and non-significant for group D (23% vs 13%). There were no patients with stroke, seizure, limb ischemia, extraocular tumor extension, secondary leukemia, metastasis, or death.

CONCLUSIONS

The current era of retinoblastoma management using intra-arterial chemotherapy plus additional intravitreal chemotherapy (as needed for vitreous seeding) has improved globe salvage in eyes with advanced retinoblastoma. [J Pediatr Ophthalmol Strabismus. 2016;53(5):275-284.].

Simultaneous Bilateral Ophthalmic Artery Chemosurgery for Bilateral Retinoblastoma (Tandem Therapy)

Objective

Report on the 7-year experience with bilateral ophthalmic artery chemosurgery (OAC-Tandem therapy) for bilateral retinoblastoma.

Design

Retrospective, single institution study.

Subjects

120 eyes of 60 children with bilateral retinoblastoma treated since March 2008.

Methods

Retrospective review of all children treated at Memorial Sloan Kettering with bilateral ophthalmic artery chemosurgery (Melphalan, Carboplatin, Topotecan, Methotrexate) delivered in the same initial session to both naïve and previously treated eyes.

Main Outcome Measures

Ocular survival, metastatic disease, patient survival from metastases, second cancers, systemic adverse effects, need for transfusion of blood products, electroretinogram before and after treatment.

Results

116 eyes were salvaged (4 eyes were enucleated: 3 because of progressive disease, 1 family choice). Kaplan Meier ocular survival was 99.2% at one year, 96.9% at 2 and 3 years and 94.9% for years 4 through 7. There were no cases of metastatic disease or metastatic deaths with a mean follow-up of 3.01 years. Two children developed second cancers (both pineoblastoma) and one of them died. Transfusion of blood products was required in 3 cases (4 transfusions), 1.9%. Two children developed fever/neutropenia requiring hospitalization (0.95%). ERGs were improved in 21.6% and unchanged after treatment in 52.5% of cases (increase or decrease of less than 25μV).

Conclusions

Bilateral ophthalmic artery chemosurgery is a safe and effective technique for managing bilateral retinoblastoma-even when eyes are advanced bilaterally, and if both eyes have progressed after systemic chemotherapy. Ocular survival was excellent (94.9% at 8 years), there were no cases of of metastatic disease and no deaths from metastatic disease, but children remain at risk for second cancers. In 21.6% of cases ERG function improved. Despite using chemotherapy in both eyes in the same session, systemic toxicity was low.

Intravitreal Lower-Dose (20 µg) Melphalan for Persistent or Recurrent Retinoblastoma Vitreous Seeds

BACKGROUND AND OBJECTIVE

The major cause of failure in the management of retinoblastoma is the persistence/recurrence of vitreous seeds (VS). This study reports the efficacy and complications of standard lower-dose (20 µg) intravitreal melphalan for VS.

PATIENTS AND METHODS

Retrospective review of all patients with active VS treated with lower-dose intravitreal melphalan (20 µg/0.1 mL) on a monthly basis until complete VS regression was achieved.

RESULTS

A total of 14 injections were delivered to seven eyes of seven patients (range: 1-4; median: 2). At a median follow-up of 20 months (range: 12-32 months), complete regression of VS was achieved in all cases (100%), and globe salvage was achieved in six cases (86%). One eye required enucleation for solid tumor recurrence. Side effects of retinal pigment epithelium mottling at the site of injection was noted in two eyes (29%).

CONCLUSION

The 2-year results of this study suggest that standard lower-dose (20 µg) intravitreal melphalan is safe and highly effective for the management of viable VS from retinoblastoma.

Targeting Survivin Enhances Chemosensitivity in Retinoblastoma Cells and Orthotopic Tumors

Treatments for retinoblastoma (Rb) vary depending on the size and location of the intraocular lesions and include chemotherapy and radiation therapy. We examined whether agents used to treat Rb induce a pro-survival phenotype associated with increased expression of survivin, a member of the inhibitor of apoptosis family of proteins. We document that exposure to carboplatin, topotecan or radiation resulted in elevated expression of survivin in two human Rb cell lines but not in normal retinal pigmented epithelial (RPE) cells. Cellular levels of survivin were attenuated in Rb cells exposed to an imidazolium-based survivin suppressant, Sepantronium bromide (YM155). Protein expression patterns of survivin in RPE cells were not altered following treatment protocols involving exposure to YM155. Including YM155 with chemotherapy or radiation increased levels of apoptosis in Rb cells but not in RPE cells. Intraocular luciferase expressing Rb tumors were generated from the Rb cell lines and used to evaluate the effects of carboplatin and YM155 on in-vivo survivin expression and tumor growth. Carboplatin induced expression of survivin while carboplatin combined with YM155 reduced survivin expression in tumor bearing eyes. The combination protocol was also most effective in reducing the rate of tumor regrowth. These results indicate that targeted inhibition of the anti-apoptotic protein survivin provides a therapeutic advantage for Rb cells and tumors treated with chemotherapy.

Molecular diagnosis in patients with retinoblastoma: Report of a series of cases

OBJECTIVES

To report the benefits of genetic diagnosis in patients with retinoblastoma.

METHOD

Observational study. Patients with retinoblastoma and their families were included. Demographic and clinical data were recorded. Blood and tumour samples were obtained. Next generation sequencing was performed on the samples. When deletion 13 q syndrome was suspected, cytogenetics microarray was performed (Cytoscan® HD, Affymetrix, Santa Clara, CA, USA), with a high density chip of 1.9 million of non-polymorphic probes and 750 thousand SNP probes.

RESULTS

Of the 7 cases were analysed 4 were male. The mean age at diagnosis was 21 months (range 5-36). Three cases had bilateral retinoblastoma, and 4 unilateral. None had family history. In all patients, blood was analysed, and a study was performed on the tissue from 2 unilateral enucleated tumours, in which 6 mutations were identified, all de novo. Just one was novel (c.164delC; case 1). One case of unilateral tumour revealed blood mosaicism, showing that his condition was inheritable, and that there is a high risk of developing retinoblastoma in the unaffected eye. The patient also has an increased risk of presenting with other primary tumours.

CONCLUSION

Molecular diagnosis of RB1 in patients with retinoblastoma impacts on the decision process, costs, treatment, and prognosis of patients, as well as their families.

Unilateral Retinoblastoma Managed With Intravenous Chemotherapy Versus Intra-Arterial Chemotherapy. Outcomes Based on the International Classification of Retinoblastoma

PURPOSE

The objective of this study was to compare outcomes after intravenous chemotherapy (IVC) versus intra-arterial chemotherapy (IAC) for unilateral retinoblastoma.

DESIGN

A retrospective comparative interventional case series.

METHODS

Patients with unilateral retinoblastoma managed with either IVC using vincristine, etoposide, and carboplatin or IAC using melphalan with or without topotecan with a minimum of 1-year follow-up were compared. The primary outcome measure was globe salvage.

RESULTS

Of 91 patients with unilateral retinoblastoma, IVC was employed in 42 (46%) cases and IAC in 49 (54%). By comparison (IVC vs IAC), patients in the IAC group had greater mean tumor diameter (14 vs 18 mm, P < 0.001) and thickness (7 vs 10 mm, P = 0.001), greater percentage with active vitreous seeds (29% vs 55%, P = 0.01), and greater total retinal detachment (10% vs 43%, P < 0.001). There were no cases of group A in either treatment arm. Globe salvage was not significantly different in groups B, C, or E, but there was significantly improved globe salvage with IAC for group D (48% vs 91%, P = 0.004). Control was significantly better with IAC for solid tumor (62% vs 92%, P = 0.002), subretinal seeds (31% vs 86%, P = 0.006), and vitreous seeds (25% vs 74%, P = 0.006). There were no patients with pinealoblastoma, second cancer, metastasis, or death in either group.

CONCLUSIONS

For unilateral retinoblastoma, IAC provided significantly superior globe salvage compared with IVC for group D eyes. In addition, IAC provided significantly superior control for solid tumor, subretinal seeds, and vitreous seeds.