Chemotherapy for eye cancer

CD71-Specific Aptamer Conjugated with Monomethyl Auristatin E for the Treatment of Uveal Melanoma

Uveal melanoma (UM) is the most common primary intraocular malignancy among adults. Despite significant advances in diagnosis and treatment, the general mortality of UM remains alarmingly high. This calls for the development of new approaches for the treatment of UM, such as targeted cancer therapy. CD71, also known as transferrin receptor 1, is overexpressed in UM cell lines and tissues. Herein, we report the development of a CD71-specific aptamer targeting the XQ-2d-MMAE conjugate that can distinguish UM cells from normal human uveal melanocytes. The cytotoxic drug monomethyl auristatin E (MMAE) could be easily coupled onto XQ-2d, a DNA aptamer that specifically targets CD71, to achieve efficiently targeted cancer growth inhibition in a mouse xenograft model, thus implying that XQ-2d-MMAE might be developed into a promising novel anti-tumor agent for the treatment of UM. Collectively, our results demonstrated that CD71 is a reliable target for drug delivery in UM and could be utilized as a model to explore aptamer-mediated targeted UM treatment strategies.

The Use of TAT Peptide-Functionalized Graphene as a Highly Nuclear-Targeting Carrier System for Suppression of Choroidal Melanoma

Tumorous metastasis is a difficult challenge to resolve for researchers and for clinicians. Targeted delivery of antitumor drugs towards tumor cells' nuclei can be a practical approach to resolving this issue. This work describes an efficient nuclear-targeting delivery system prepared from trans-activating transcriptional activator (TAT) peptide-functionalized graphene nanocarriers. The TAT peptide, originally observed in a human immunodeficiency virus 1 (HIV-1), was incorporated with graphene via an edge-functionalized ball-milling method developed by the author's research group. High tumor-targeting capability of the resulting nanocarrier was realized by the strong affinity between TAT and the nuclei of cancer cells, along with the enhanced permeability and retention (EPR) effect of two-dimensional graphene nanosheets. Subsequently, a common antitumor drug, mitomycin C (MMC), was covalently linked to the TAT-functionalized graphene (TG) to form a nuclear-targeted nanodrug MMC-TG. The presence of nanomaterials inside the nuclei of ocular choroidal melanoma (OCM-1) cells was shown using transmission electron microscopy (TEM) and confocal laser scanning microscopy. In vitro results from a Transwell co-culture system showed that most of the MMC-TG nanodrugs were delivered in a targeted manner to the tumorous OCM-1 cells, while a very small amount of MMC-TG was delivered in a non-targeted manner to normal human retinal pigment epithelial (ARPE-19) cells. TEM results further confirmed that apoptosis of OCM-1 cells was started from the lysis of nuclear substances, followed by the disappearance of nuclear membrane and cytoplasm. This suggests that the as-synthesized MMC-TG is a promising nuclear-target nanodrugfor resolution of tumorous metastasis issues at the headstream.

Nanomedicine in the application of uveal melanoma

Rapid advances in nanomedicine have significantly changed many aspects of nanoparticle application to the eye including areas of diagnosis, imaging and more importantly drug delivery. The nanoparticle-based drug delivery systems has provided a solution to various drug solubility-related problems in ophthalmology treatment. Nanostructured compounds could be used to achieve local ocular delivery with minimal unwanted systematic side effects produced by taking advantage of the phagocyte system. In addition, the in vivo control release by nanomaterials encapsulated drugs provides prolong exposure of the compound in the body. Furthermore, certain nanoparticles can overcome important body barriers including the blood-retinal barrier as well as the corneal-retinal barrier of the eye for effective delivery of the drug. In summary, the nanotechnology based drug delivery system may serve as an important tool for uveal melanoma treatment.

Longitudinal trends in use of targeted therapies for treatment of malignant neoplasms of the eye: a population-based study in Taiwan

OBJECTIVES

This study examined the recent trend in use and costs of antineoplastic agents for treatment of eye malignancies in Taiwan from 2009 to 2012. We also forecasted use and costs of targeted therapies up to and including year 2016 based on the current patterns.

DESIGN

Retrospective observational study focusing on the usage of targeted therapies for treatment of eye malignancy.

SETTING

The monthly claims data for eye malignancy-related antineoplastic agents were retrieved from Taiwan's National Health Insurance Research Database (2009-2012).

MAIN OUTCOME MEASURES

We calculated the number of prescriptions and costs for each class of medications, and analysed their time trends. In addition, using a time series design with ARIMA models, we estimated the market share by prescription volume and the proportion of costs for targeted therapies for year 2016.

RESULTS

The market share by prescription volume of targeted therapies grew from 1.56% in 2009 to 9.98% in 2012 among all antineoplastic agents, and the proportion of costs for targeted therapies rose from 15.12% in 2009 to 58.88% in 2012. Especially, the proportion of costs for protein kinase inhibitors grew from 25.62% to 45.28% among all antineoplastic agents between 2010 and 2012. The market share by prescription volume and the proportion of costs for targeted therapies for treatment of eye malignancies were predicted to reach 27.33% and 91.39% by the fourth quarter in 2016, respectively.

CONCLUSIONS

This is the first study that examined and forecasted use and costs of targeted therapies for treatment of eye malignancies in Taiwan. Our findings indicate that, compared with other classes of drugs, targeted therapies are having a more and more relevant share among all treatment strategies for eye malignancies in Taiwan, and due to their high costs they are likely to cause great economic burden.

Conjunctival melanoma: a review of conceptual and treatment advances

The aim of this study was to review the available literature and identify recent advances in the classification and management of conjunctival melanoma (CM) for clinicians working in this field. English-based articles were identified using the MEDLINE^® database, and additional cited works not detected in the initial search were also obtained. Articles were assessed according to the Australian National Health and Medical Research Council levels of evidence criteria. Review of the literature indicated that the current classification and management of CM is predominantly based upon primarily nonrandomized, single-institution, retrospective case series. While these studies provide the basis for the recent seventh edition of the tumor node metastasis staging classification, this classification more accurately reflects the current knowledge of prognostic factors for CM. Application of this revised classification system together with prospective trials will provide the opportunity for future consistent and comparable data collection across centers, and it will improve the quality of evidence upon which current classification and management of CM is based. Furthermore, the high risk of local recurrence with current standard management suggests that adjuvant therapy, particularly mitomycin C and/or brachytherapy, may improve outcomes regardless of clinical staging. Finally, the use of sentinel lymph node biopsy may have significant benefit for a select group of CM patients.

Exophthalmos as a first manifestation of small cell lung cancer: a long-term follow-up

Small cell lung cancer is characterized by rapid growth and early metastasis. Despite its sensitivity to cytotoxic therapy, until now treatments have failed to control or cure this disease in most patients. Orbital metastases are a rare manifestation of systemic malignancies. Breast and lung cancers represent more than two thirds of the primary cancer sites. Metastases to the eye and orbit develop in approximately 0.7–12% of patients with lung cancer. Here, we report a rare case of exophthalmos as the first manifestation of a metastatic carcinoma due to small cell lung cancer, and a 6-months follow-up with complete exophthalmic response to chemotherapy.

Cancer of the orbit and adnexa

The diagnosis and treatment of orbital and periorbital malignancies are challenging. These tumors can result in blindness, death, and significant cosmetic deformities. Herein, we present the most common ocular malignancies and a systematic approach to diagnosis. Further, we integrate the seventh edition American Joint Committee on Cancer staging system, biomarkers, and multidisciplinary approaches to treatment.

Orbital metastases as the first manifestation of lung adenocarcinoma

Reduction in visual acuity due to orbital metastasis is rarely the first sign of lung cancer and very few cases have been published in the literature. Here we report a rare case of lung adenocarcinoma with orbital metastasis as the first presenting sign. The incidence of primary tumors that metastasize to the orbit is approximately 7%. In 19% of the cases, there is no history of cancer when the patient presents with ophthalmic symptoms, and in 10%, the primary site remains obscure despite intensive systemic evaluation. Our patient showed a partial improvement in vision after successful combination of chemotherapy and radiotherapy. Blurred vision due to orbital metastasis as the primary symptom of lung cancer is very uncommon. A great index of suspicion is essential when an orbital lesion appears.

Eye-preserving therapy in retinoblastoma: prolonged primary chemotherapy alone or combined with local therapy

Purpose

To evaluate the efficacy of primary chemotherapy combined with local therapy in the treatment of retinoblastomas not treatable with a single therapeutic method.

Methods

We performed a retrospective chart review of 227 patients diagnosed with retinoblastoma. Sixty-five eyes in 52 patients had tumors not treatable with a single therapeutic method and received primary chemotherapy combined with local therapy as needed.

Results

Tumor control and eye salvage was achieved in 34 of the 65 eyes; the probability of ocular survival was 46.56% using the Kaplan-Meier method. Forty-three of the 65 eyes were group D or E tumors, in which tumor control and eye salvage was achieved in 16 eyes. Twenty eyes were treated with chemotherapy only, while 28 eyes received one additional modality of local therapy, and 17 eyes received two modalities of local therapy. Of the eyes treated with chemotherapy only, tumor control was achieved in 5 eyes.

Conclusions

Primary chemotherapy combined with local therapy can be effective and safe in the treatment of retinoblastomas otherwise untreatable with other therapeutic methods, such as group D and E retinoblastomas. More vigorous treatment with more local therapeutic methods combined may yield even better results.

NANOTECHNOLOGY IN THE TREATMENT AND DETECTION OF INTRAOCULAR CANCERS

Tremendous progress in nanotechnology has lead to the development of nanometer-sized objects as medical implants or devices. Many of these nanodevices have recently been tested in many cancer diagnostic and therapeutic applications, such as leukemia, melanoma, breast tumor, prostate tumor, and brain cancer. Despite the increasing importance of nanotechnology in cancer, the potential of these nanodevices in diagnosing and treating intraocular cancers has not been systematically evaluated. This review summarizes the significant advancements and potential areas for development in the field of nanotechnology-based intraocular drug delivery and imaging.

Topical interferon alfa in the treatment of conjunctival melanoma and primary acquired melanosis complex

PURPOSE

To report on topical interferon alfa-2b for conjunctival malignant melanoma (CMM) and primary acquired melanosis with atypia (PAM).

DESIGN

Retrospective, interventional case series.

METHODS

Five eyes of five consecutive patients with biopsy-proven malignant melanoma were treated with topical interferon alfa-2b as treatment for primary or recurrent disease. One drop of interferon alfa-2b (1 million units/ml) was placed into the superior fornix four times daily for three months. Punctal plugs limited systemic absorption. The main outcome measure was tumor regression by clinical examination and comparative slit-lamp photography.

RESULTS

Five consecutive patients with conjunctival melanoma (American Joint Committee on Cancer-International Union Against Cancer stages T2 [n = 3] and T3 [n = 2]) were included. Two patients had recurrent corneal tumors, eight and 13 months after local excision, cryotherapy, and topical mitomycin C therapy. Two months after topical interferon alfa-2b treatment, the lesions regressed without side effects. Two additional patients (who could not tolerate topical mitomycin C) were switched to topical interferon alfa-2b. They experienced transient chemical conjunctivitis and have no signs of recurrence (mean, 15 months of follow-up). The fifth had recurrent tumor despite multiple surgeries. This melanoma did not respond to topical interferon alfa-2b nor did the patient tolerate treatment (keratoconjunctivitis). No systemic side effects were noted.

CONCLUSIONS

We present evidence that conjunctival and corneal melanoma regresses after exposure to topical interferon alfa-2b. A larger-scale longer-term study must evaluate the long-term efficacy and safety of this therapy.

Vesicular stomatitis virus induces apoptosis in the Wong–Kilbourne derivative of the Chang conjunctival cell line

BACKGROUND

Virotherapy represents a novel therapeutic modality for the treatment of malignant diseases. Vesicular stomatitis virus (VSV) has been shown to exert antitumor effect in several tumor types. Since the potential oncolytic activity of VSV has not yet been evaluated in epithelial tumors of the conjunctiva, we set out to investigate the susceptibility of the immortalized Wong-Kilbourne derivative of the Chang conjunctival cell line (WK) to VSV and analyze the role of apoptosis in VSV-mediated induction of cell death.

METHODS

WK cells were infected with VSV at various multiplicities and maintained for different periods of time. VSV-infected cells were analyzed by inverted microscopy for the development of cytopathic effects (CPE). Virus replication was measured by indirect immunofluorescence assay, Western blot analysis and plaque titration. The apoptotic response of the infected cells was quantitated by ELISA detecting the enrichment of nucleosomes in the cytoplasm. Western blot analysis was used to determine the levels of Bcl-2 and Bax proteins.

RESULTS

The WK cell line was highly permissive to VSV replication and was highly susceptible for the CPE of this virus. VSV infection elicited the apoptotic death of WK cells. Mock-infected cells exhibited endogenous expression of Bcl-2 and p21 Bax proteins. VSV infection caused a significant decrease in the expression level of Bcl-2. Moreover, in parallel with a slight decrease in the level of p21 Bax, p18 Bax protein accumulated in VSV-infected WK cells.

CONCLUSIONS

VSV is a powerful inducer of apoptosis in immortalized WK cells. The VSV-mediated alterations in the expressions of Bcl-2 and Bax proteins may play important roles in the apoptotic responses of infected cells and may also sensitize to other apoptotic stimuli. This virus may possess oncolytic activity in epithelial tumors of the conjunctiva.

"Finger-tip" cryotherapy probes: treatment of squamous and melanocytic conjunctival neoplasia

AIM

To describe the use of a new spatulated cryoprobe in treatment of conjunctival neoplasia.

METHODS

A new cryoprobe design was submitted to Mira, Inc resulting in new hand held probes capable of producing homogeneous freezing over large surface areas. The active surface of the small, medium, and large spatulated probes are 8.5 mm2, 25.2 mm2, and 70 mm2. End freezing reduces the possibility of inadvertent freezing of adjacent tissues (outside the targeted zone). In this series, the probes were employed to treat patients with squamous and melanocytic conjunctival neoplasia.

RESULTS

12 consecutive patients with malignant conjunctival neoplasia were treated with these new cryotherapy probes. Techniques of probe construction and clinical use are described. Cryoburns of the cornea, sclera, and conjunctiva were formed and recorded by digital photography. Ophthalmic examinations before and after surgery demonstrated that no acute intraocular or adnexal complications occurred. No loss of visual acuity could be attributed to this use of the cryoprobes.

CONCLUSION

"Finger-tip" cryoprobes were used to treat malignant conjunctival neoplasia (squamous and melanocytic). Probe design allowed for uniform freezing over large surface areas. This cryoprobe design appears to be ideal for treatment of conjunctival tumours.

Whole body positron emission tomography/computed tomography staging of metastatic choroidal melanoma

PURPOSE

To evaluate whole-body positron emission tomography (PET)/computed tomography in staging of patients with metastatic choroidal melanoma.

DESIGN

Interventional non-randomized clinical study.

METHODS

Twenty patients were referred for whole-body 18-fluoro-2-deoxy-D-glucose (FDG) PET/computed tomography imaging because of suspected metastatic choroidal melanoma. PET/computed tomography images were studied for the presence and distribution of metastatic melanoma. Subsequent biopsies were performed to confirm the presence of metastatic disease.

RESULTS

Twenty patients underwent PET/computed tomography. Eighteen were imaged because of abnormal clinical, hematologic, or radiographic screening studies during the course of their follow-up after plaque brachytherapy or enucleation. Two were imaged before treatment of their primary tumor. PET/computed tomography revealed or confirmed metastatic melanoma in eight (40%) of these 20 patients. The mean time from initial diagnosis to metastasis was 47 months (range 0 to 154). The most common sites for metastases were the liver (100%), bone (50%), lung (25%), lymph nodes (25%), and subcutaneous tissue (25%). Cardiac, brain, thyroid, and posterior abdominal wall lesions (12.5%) were also noted. Six patients (75%) had multiple organ involvement. No false positives were noted. PET/computed tomography imaging also detected benign lesions of the bone and lymph nodes in three patients (15%). All patients had hepatic metastases and liver enzyme assays were abnormal in only one (12.5%) of eight patients.

CONCLUSIONS

PET/computed tomography imaging is a sensitive tool for the detection and localization of hepatic and extra-hepatic (particularly osseous) metastatic choroidal melanoma.

Topical mitomycin chemotherapy for conjunctival malignant melanoma and primary acquired melanosis with atypia: 12 years' experience

PURPOSE

To report 12-year follow-up experience with topical mitomycin chemotherapy for diffuse and multifocal primary acquired melanosis (PAM) with atypia and conjunctival melanoma.

METHODS

Interventional case series of 16 patients. Mitomycin was a primary treatment for residual epithelial disease in ten patients (eight with PAM with atypia and two with conjunctival melanoma) and as an adjuvant to excision and cryotherapy in six with conjunctival malignant melanoma. Primary treatments consisted of mitomycin 0.04% qid for 28 days (two 14-day cycles) and for 7 consecutive days as adjuvant therapy. Patients were followed for both local recurrence and metastatic disease.

RESULTS

Sixteen patients were followed for a mean 81 months (range 13-144 months) after treatment. All tumors responded to chemotherapy. Recurrence was noted in eight (three adjuvant and five primary treatment patients). Three underwent orbital exenteration. The remaining five were treated conservatively. The mean time to recurrence was 36.9 months. The short-term mitomycin-related complications included transient keratoconjunctivitis (n=14), severe keratoconjunctivitis (n=1) and one corneal abrasion with scar formation. The long-term complications included pannus (n=2) and corneal haze (n=1). Visual acuity was maintained within two lines in 14 patients (including measurements just prior to exenteration). Three patients died, one of metastatic conjunctival melanoma.

CONCLUSIONS

Conjunctival melanoma and PAM responded to mitomycin 0.04% topical chemotherapy; subepithelial nests appeared resistant to treatment. Treatment-related complications were acceptable. In this series, as primary and adjuvant therapy, topical mitomycin yielded an overall recurrence rate of 50%.

Choroidal metastasis: case reports and review of the literature

BACKGROUND

Choroidal metastases are recognized as the most common intraocular malignancy. Their diagnosis has become more common due to increased emphasis on comprehensive eye examinations for cancer patients and the improved life expectancy of patients with metastatic disease. They are most prevalent in female patients with breast cancer and male patients with lung cancer.

METHODS

A thorough fundus examination, coupled with the use of A-scan and B-scan ultrasonography, will aid in their diagnosis. There are many ways of treating these tumors, including radiation therapy, chemotherapy, and monitoring.

CASE REPORTS

Two case reports of patients diagnosed with choroidal metastases are discussed. Case 1 involved a patient with lung cancer who manifested a large bullous exudative retinal detachment due to an underlying choroidal metastasis. Case 2 dealt with treatment of a patient with metastatic transitional cell cancer who manifested a shallow exudative retinal detachment caused by a choroidal metastasis.

CONCLUSIONS

Due to progress of chemotherapeutic medications, the number of patients who manifest choroidal metastases will continue to increase. It is essential for the practitioner to be able to recognize this disease process to prevent visual loss and institute referral for proper treatment for metastatic disease.

Expression and amplification of therapeutic target genes in retinoblastoma

PURPOSE

We set out to evaluate alterations of the therapeutic target genes KIT (CD 117), EGFR, and HER-2 in human retinoblastoma.

METHODS

Ninety-five formalin-fixed, paraffin-embedded retinoblastomas were brought into a tissue microarray (TMA) format. Immunohistochemistry was performed to analyze the expression of CD117, EGFR, and HER-2. Fluorescence in situ hybridization (FISH) was utilized for detection of EGFR amplifications. Three tumors with strong CD117 positivity were sequenced for KIT exon 11 mutations.

RESULTS

Detectable CD117 expression was seen in 19% of all interpretable cases. Sequence analysis of the three tumors with the strongest CD117 expression revealed no mutations. EGFR was positive in 14% of all cases. No EGFR amplification was observed by FISH, however. All tumors were negative for HER-2 expression.

CONCLUSIONS

Our data suggest that selected cases of retinoblastoma may be candidates for anti-EGFR and imatinib mesylate (STI571) therapy.

Visual recovery after radiation therapy for bilateral subfoveal acute myelogenous leukemia (AML)

PURPOSE

Present a case of bilateral foveal acute myelogenous leukemic tumors that responded to radiation therapy.

DESIGN

Case report.

METHODS

A patient was diagnosed with bilateral subfoveal infiltration of known systemic acute myelogenous leukemia. He received a standard induction chemotherapy, followed by consolidation therapy for his systemic leukemia. However, despite a complete marrow response, the intraocular tumors did not regress. Therefore, he was given low dose (1950-cGy) ocular external beam radiation therapy.

RESULTS

One course of systemic cytarabine chemotherapy failed to control the subfoveal tumors, leaving the patient at risk for permanent vision loss. In contrast, external beam radiation therapy improved his vision from 20/60 in his right eye to 20/20 and from 20/70 in his left eye to 20/25.

CONCLUSION

Although systemic chemotherapy can be used to treat intraocular metastasis, external beam radiation may provide more prompt resolution of vision-threatening tumors.

Treatment of recurrent corneal and conjunctival intraepithelial neoplasia with topical interferon alfa 2b

OBJECTIVE

To evaluate topical interferon alfa 2b (IFNalpha2b) as a single therapeutic agent in the treatment of presumed recurrent corneal and conjunctival intraepithelial neoplasia.

DESIGN

Noncomparative, retrospective case series.

PARTICIPANTS

Seven consecutive patients with recurrent corneal and conjunctival intraepithelial neoplasia diagnosed at the University of Minnesota from July 2000 to November 2003 were studied retrospectively. All patients had a history of histologically proven primary corneal and conjunctival intraepithelial neoplasia and were treated by surgery, cryotherapy, radiation, and/or topical mitomycin C before recurrence.

INTERVENTION

Patients with a clinical diagnosis of recurrent corneal and conjunctival intraepithelial neoplasia were treated with recombinant topical IFNalpha2b drops (1 million IU/ml) 4 times daily until lesion resolution was noted.

MAIN OUTCOME MEASURES

A review of medical records was performed to assess the duration of and response to treatment with topical IFNalpha2b, defined by clinical resolution of corneal and conjunctival intraepithelial neoplasia.

RESULTS

The average age of the 7 patients at the initiation of topical IFNalpha2b treatment for presumed recurrent corneal and conjunctival intraepithelial neoplasia was 68.7 years (range, 54-88). Six of 7 patients had successful treatment of recurrent corneal and conjunctival intraepithelial neoplasia lesions with topical IFNalpha2b treatment. The average length of IFNalpha2b treatment to resolution of recurrent corneal and conjunctival intraepithelial neoplasia was 14.5 weeks (range, 5-24). After treatment with topical IFNalpha2b for recurrent corneal and conjunctival intraepithelial neoplasia, 2 patients had another recurrence of corneal and conjunctival intraepithelial neoplasia, noted at 1 year and 2 months, respectively. The average post-treatment follow-up was 11.7 months (range, 8-17) after the resolution of recurrent corneal and conjunctival intraepithelial neoplasia. No side effects of treatment were noted in any patient.

CONCLUSIONS

Topical IFNalpha2b as a single therapeutic agent is an effective treatment of presumed recurrent corneal and conjunctival intraepithelial neoplasia. It offers the benefits of topical therapy and avoids the risks of surgical or other interventions-specifically, ocular surface toxicity, cicatricial conjunctival changes, and limbal stem cell deficiency. Larger controlled studies with longer follow-up periods are recommended to confirm the long-term efficacy and safety of this topical treatment.

Anterior segment tumors: current concepts and innovations

The most common anterior segment tumors are primary neuroepithelial cysts, uveal melanomas, metastatic tumors, and benign tumors. In the majority of cases, the diagnosis can be made utilizing a careful clinical history and ocular examination. Ultrasound examination (low and high frequency) has become an indispensable tool used to determine tumor extension and involvement of the surrounding structures. In particular, high-frequency ultrasound has been used to uncover iris pigment epithelial cysts, to allow for the diagnosis of small ciliary body melanomas, and to measure tumors for plaque radiation planning. Whereas fluorescein angiography and computerized tomography have come to play a limited role, fine-needle aspiration biopsy has been found to be quite helpful in selected cases. Once the diagnosis is established, treatment decisions depend on the tumors' location, size, local extension, patterns of growth, and secondary complications. Most anterior segment tumors can be observed for growth prior to treatment. Other options include local resection (iridectomy, lamellar sclerouvectomy, or eye-wall resection) and radiation (ophthalmic plaque or external beam). Enucleation is typically employed if these eye- and vision-sparing treatments are not possible and for uncontrollable secondary glaucoma. This review examines the unique role of high-frequency ultrasonography for the diagnosis and treatment of anterior segment tumors as well as an overview of clinical practice.

The chemosensitivity profile of retinoblastoma

Retinoblastoma is a rare malignant tumour of the developing retina with an incidence of 1 in 20,000 live births in all human races. Chemotherapy is used in retinoblastoma as adjuvant therapy to prevent the growth of metastases and to treat metastatic disease once this has become clinically apparent. Current regimens are based on empirical drug combinations, and few clinical trials have been conducted because of the rarity of this tumour. Chemosensitivity testing offers a way of testing a large number of agents against tumours. The ATP-based chemosensitivity assay (ATP-TCA) has already helped to design new regimens for melanoma and breast and ovarian cancer. Primary retinoblastoma tumour material was obtained from 10 eyes, 7 of which contained sufficient viable cells for ATP-TCA. The results show very high sensitivity to single agents, particularly cisplatin, doxorubicin and vinca aLkaloids. Of the anti-metabolites tested, 5-FU is relatively disappointing (although still active), and gemcitabine shows considerable activity consistent with a cytotoxic effect. The shape of the inhibition curves is interesting. There is a plateau effect with the topoisomerase inhibitors and vinblastine, which is not present with the cisplatin. One tumour was much more resistant than the others tested, particularly to vinblastine but also to the topoisomerase inhibitors, which failed to achieve complete kill at any concentration tested, consistent with a multidrug resistance phenotype. Of the combinations (VAC and VEC), the VAC regimen looks marginally more active in the more resistant of the two cases tested to date. These data confirm that retinoblastoma is a rapidly growing malignancy that is very susceptible to cytotoxic drugs of all types. Chemosensitivity testing provides a practical method of testing new regimens before clinical trials in retinoblastoma patients.

Choroidal metastasis from adenoid cystic carcinoma of the lung

PURPOSE

We report a case of a choroidal metastasis from an adenoid cystic carcinoma of the lung. Interventional case report.

DESIGN

A 40-year old man, 9 months' status postresection of a bronchial adenoid cystic carcinoma, was diagnosed by clinical evaluation and fine-needle aspiration biopsy and treated with palladium-103 ophthalmic plaque brachytherapy.

RESULTS

This unusual patient with uveal metastasis from adenoid cystic carcinoma presented with decreased vision in the right eye and a diaphanous amelanotic choroidal tumor in the superotemporal macula. Ultrasound revealed a dome-shaped tumor that measured 4.0 mm in apical height and 11 x 10 mm in basal diameter. Fluorescein angiography revealed a double circulation and late intense subretinal fluorescence. Plaque brachytherapy provided local control and preservation of the eye.

CONCLUSION

Bronchogenic adenoid cystic carcinoma can metastasize to the choroid.

Thermochemotherapy in hereditary retinoblastoma

BACKGROUND/AIM

The combination of chemotherapy and transpupillary thermotherapy, thermochemotherapy (TCT) has become an established part of the treatment plan in advanced retinoblastoma. The aim of this study was to identify safe indications, the complications as well as the limitations of this new treatment for retinoblastoma.

METHODS

Tumour response and side effects of TCT with an indirect laser ophthalmoscope (spot size about 400 micro m) in 55 tumours of 26 children with bilateral retinoblastoma were analysed. Using the Reese-Ellsworth classification system, nine of 35 eyes were classified as type I, 13 eyes as type II, 10 eyes as type III, and three eyes as type V. The mean age of the children was 0.74 (SD 0.61) years. The mean tumour height was 3.5 (2.3) mm with a mean diameter of 6.1 (4.1) mm. Treatment parameters were 4.3 (1.6) (median 5) thermochemotherapy sessions with a mean energy of 539 (211) mW and a mean duration of 13.5 (5.6) minutes. Chemotherapy courses (vincristine, etoposide, and carboplatin) were repeated every 3 weeks. The mean follow up period was 1.25 (0.6) years.

RESULTS

Local recurrence occurred in 21 tumours (38%), with a mean onset of 3.2 (2.9) months after TCT. The risk of tumour recurrence was correlated with tumour height. The recurrence rate was 17% for tumours with a height less than 2 mm, 37% for tumours with a height between 2 and 4 mm, and 63% for larger retinoblastomas. Multivariate analysis identified fish flesh regression after TCT (p = 0.0007) as the most important risk factor for tumour recurrence besides tumour height (p = 0.001) and the necessity of increased laser power during TCT sessions (p = 0.018). Complications during therapy included transient corneal opacification in two eyes (6%), focal iris atrophy (three eyes, 8.5%), peripheral lens opacity (two eyes, 6%), circumscribed transient retinal detachment (one eye, 3%) and diffuse choroidal atrophy (one eye, 3%).

CONCLUSION

TCT using an indirect laser ophthalmoscope with a spot size of about 400 micro m was efficient for retinoblastoma with a tumour height less than 4 mm. In larger tumours, the recurrence rate was unacceptably high. Fish flesh regression after TCT correlates with a higher rate of local tumour recurrence. Treatment related complications occurred in less than 9% of the treated eyes.

Rhabdomyosarcoma: review for the ophthalmologist

Rhabdomyosarcoma is a malignant neoplasm that is composed of cells with histopathologic features of striated muscle in various stages of embryogenesis. It can occur in several sites in the body, including the ocular region. Ocular rhabdomyosarcoma is defined as the occurrence of this tumor in the area of the eye. Most ocular rhabdomyosarcomas arise in the soft tissues of the orbit but they can rarely occur in the other ocular adnexal structures and even within the eye. The purpose of this review is to provide a brief overview of rhabdomyosarcoma and a more detailed review of orbital rhabdomyosarcoma, with emphasis on changing concepts in the diagnosis and management of this ophthalmic neoplasm.

Three dimensional ultrasound of retinoblastoma: initial experience

AIM

To use 3D ultrasonography (3DUS) for the diagnosis of retinoblastoma.

METHODS

Five eyes of three children with retinoblastoma were evaluated using a commercially available computerised 3DUS system. Interactive sectioning of the stored and reconstructed 3D volumes were performed. 3DUS and histopathological findings were correlated after enucleation.

RESULTS

3DUS examination revealed characteristics consistent with retinoblastoma: endophytic mass, retinal detachment, intratumoural calcifications, and secondary orbital shadowing. Unlike 2D imaging, 3DUS allowed for analysis of the acquired and stored volumes. Rotation and sectioning of this volume allowed the discovery of new oblique and coronal views. For example, calcium related orbital shadows were seen as 3D volumes and (coronal) cross sections of the optic nerve were evaluated for evidence of intraneural invasion by retinoblastoma.

CONCLUSION

This is the first reported series of patients examined with 3DUS imaging for retinoblastoma. This technique allowed for new oblique and coronal views of the tumour and optic nerve. The ability to retrospectively analyse the (scanned and stored) ocular volume facilitated patient care, teaching, tumour-volume analysis, and telemedicine.