Manual Small Incision 20-Gauge Pars Plana Vitrectomy

Comparison of Intra-Arterial Chemotherapy Efficacy Delivered Through the Ophthalmic Artery or External Carotid Artery in a Cohort of Retinoblastoma Patients

Purpose: To evaluate the efficacy of an external carotid artery (ECA) alternative route in intra-arterial chemotherapy (IAC) for treatment of retinoblastoma.

Methods: In this retrospective, single-centre, case-control study, 98 retinoblastoma patients who received successful IAC were included. The drug delivery routes were the primary ophthalmic artery (OA) route and the ECA route when OA catheterization was not feasible.

Results: A total of 337 successful IAC procedures were performed in our study, of which 32 (9.5%) procedures were performed through the ECA route. Eighteen eyes (18.4%) accepted at least one IAC through branches of the ECA. Statistical analysis showed that there was no significant difference in ocular clinical results (enucleation, death, recurrence and event-free) between the ECA and OA routes. No significant association was found between the route of drug delivery and the ocular survival time (p = 0.69). The use of ECA catheterization in at least one IAC cycle was not a predictor of enucleation (HR: 1.58; 95% CI: 0.56–4.46, p = 0.39). The increasing number of procedures through the ECA route did not increase the risk of enucleation (HR: 1.64; 95% CI: 0.42–6.39, p = 0.48).

Conclusion: The ECA alternative route did not affect the efficacy of IAC in retinoblastoma. When the standard OA approach is not feasible, ECA system catheterization should be considered.

The Use of Alternative Routes for the Delivery of Intra-Arterial Chemotherapy for Retinoblastoma

BACKGROUND

The introduction of intra-arterial chemotherapy (IAC) for treatment of retinoblastoma considerably changed the paradigm by which this disease is managed, with event-free survival rates being above 70%.

OBJECTIVE

To analyze efficacy of IAC treatment using alternative approaches to ophthalmic artery catheterization (OAC), such as external carotid artery approach or balloon-assisted drug delivery.

METHODS

This is a retrospective chart review for subjects receiving IAC for retinoblastoma. The primary approach was OAC. In cases in which selective OAC was not feasible, alternative routes including catheterization of the external carotid artery or use of a balloon-assisted drug infusion were used.

RESULTS

This study included 197 consecutive patients with 207 retinoblastomas who underwent 658 IAC procedures overall. The mean age at diagnosis was 24 mo, and 54.5% of the study population was male. Success rate with IAC was 97% (639). Alternative approaches to OAC were, in total, 42 cases (6.4%)-external carotid artery catheterization and use of ICA balloon were performed in 22 (3.3%) and 20 (3%) cases, respectively. A mean of 3.1 IAC cycles were performed for each patient. In total, there were 23 technical failures of the primary OAC technique (3.4%). Periprocedural adverse events occurred in 4 procedures (0.6%). Use of an alternative technique for chemotherapy delivery other than selective OAC in at least one IAC cycle was not a predictor of enucleation.

CONCLUSION

IAC is a safe and effective treatment option for retinoblastoma. Chemotherapy delivery using alternative techniques is as effective as selective OAC.

Epidemiological trends in 1452 cases of retinoblastoma from the Surveillance, Epidemiology, and End Results (SEER) registry

OBJECTIVE

To assess retinoblastoma epidemiological trends in the Surveillance, Epidemiology, and End Results (SEER) registry.

METHODS

All cases of retinoblastoma in the SEER database from 1973 to 2009 were identified. Kaplan-Meier survival analyses were performed for pathological grade, patient age, sex, year of diagnosis, and treatment modality. Cox proportional hazards regression assessed the impact of patient and tumour characteristics on survival.

RESULTS

1452 cases of retinoblastoma were analyzed. The mean patient age at diagnosis was 1.44 years. The tumour was unilateral in 71.0% and bilateral in 29.0%. The mean follow-up was 129.1 months. Overall survival increased during the study interval. Patients with bilateral tumours were diagnosed at an earlier age (0.46 years) than patients with unilateral disease (1.77 years; p < 0.0001). Bilateral retinoblastoma (90.3% 10-year overall survival) was associated with decreased overall survival than unilateral retinoblastoma (96.1% 10-year overall survival). Bilateral retinoblastoma was also associated with an increased incidence of nonocular malignancies (7.8%) compared with unilateral retinoblastoma (1.3%; p < 0.0001). Grade 1 tumours were diagnosed at a younger age (0.94 years) than grade 3 (2.24 years) and grade 4 tumours (2.14 years; p < 0.0001). Lower grade and lower stage tumours were independently associated with increased survival. In multivariate Cox proportional hazards analysis, T stage and laterality were the only covariates that correlated with overall survival.

CONCLUSIONS

There appear to be associations between retinoblastoma tumour features such as tumour stage, pathological grade, and laterality with patient characteristics such as age at diagnosis, overall survival, and second malignancies.

Anti-VEGF treatment is the key strategy for neovascular glaucoma management in the short term

Background

To present a comprehensive approach for the management of patients with neovascular glaucoma (NVG) aiming to preserve visual function and complement pan-retinal photocoagulation (PRP) by anti-vascular endothelial growth factor (anti-VEGF) treatment and anti-glaucoma surgery.

Methods

This study includes a prospective, interventional case series. A process flow chart for NVG management was designed. Totally 50 patients (51 eyes) with NVG were included. Of these, 43 patients (44 eyes) completed the treatment process. Patients were divided into central retinal vein occlusion (CRVO) and proliferative diabetic retinopathy (PDR) groups according to their original diagnosis. Intraocular pressure (IOP), visual function, and the status of iris and angle neovascularization were recorded before and after treatment.

Results

Patients were followed up for 6–30 months (mean 12.2 months). The IOP of all 44 patients was effectively controlled and was significantly less after treatment (16.68 ± 4.69 mmHg) than before treatment (42.59 ± 9.44 mmHg, P < 0.05). Thirty-nine eyes displayed controlled IOP (≤21 mmHg) after treatment. Visual acuity improved, to some extent, in 32 eyes (72.9 %), and 12 eyes (27.3 %) had a visual acuity better than 0.1. There was no significant difference in IOP between the PDR and CRVO groups at the end of follow-up (P = 0.8657), but the visual acuity in the PDR group was much better than that in the CRVO group (P = 0.0079).

Conclusions

A comprehensive therapy for NVG can effectively control IOP and preserve visual function in patients by anti-VEGF injection and anti-glaucoma surgery.

Update on intra-arterial chemotherapy for retinoblastoma

The tools for managing retinoblastoma have been increasing in the past decade. While globe-salvage still relies heavily on intravenous chemotherapy, tumors in advanced stage that failed chemotherapy are now referred for intra-arterial chemotherapy (IAC) to avoid enucleation. However, IAC still has many obstacles to overcome. We present an update on the indications, complications, limitations, success, and technical aspects of IAC. Given its safety and high efficacy, it is expected that IAC will replace conventional strategies and will become a first-line option even for tumors that are amenable for other strategies.

Outcome of retinoblastoma following limited sessions of intra-arterial chemotherapy in iran

Background:

The management of retinoblastoma remains a challenge to the multidisciplinary team, particularly as treatment affects not only visual outcomes, but also ocular retention and morbidity. Management of retinoblastoma has evolved over the past two decades.

Objectives:

To report the result of intra-ophthalmic artery chemotherapy (IAC) for the treatment of refractory and advanced retinoblastoma tumors.

Patients and Methods:

All patients who had failed to respond adequately to previous treatments and six naive patients with advanced retinoblastoma, receiving IAC between 2009 and 2012, were included in this institutional interventional case series. The patients received 1-2 treatments of IAC given 4-8 weeks apart. Complete response was defined as regressed tumor and complete disappearance of seeding clinically and partial response was defined as partial regression of the tumor with live parts of the tumor and/or lessening of seeds, but not complete disappearance of them clinically.

Results:

A total of 24 eyes of 24 patients were treated with IAC during the study period. The mean age at the time of IAC was 38.9 months (14-120 months), and the mean follow-up was 16.8 months (3-36 months) after IAC. Tumor control was achieved in 14 eyes (58.3%). Type 3 (combined fleshy and calcified remnants) was the most common type of regression (37.5%). Complications included vitreous hemorrhage in nine eyes (37.5%), arterial occlusion in two (8.3%), cyclitic membrane possibly secondary to ischemia and tractional retinal detachment in one patient (4.2%), chorioretinal atrophy in three (12.5%) patients, and neovascular glaucoma in one eye (4.2%). In eight (33.3%) patients, no complication happened. Globe salvage was achieved in 62.5% of the cases. The success rate for naive patients was 84%. Sixty-seven percent of the cases received transpupillary thermotherapy and cryotherapy before IAC.

Conclusions:

Intra-ophthalmic artery melphalan is an effective treatment for advanced cases of retinoblastoma, with a reasonable level of success. In the short follow up period of this study, it appears that the primary cases showed better results in the control of tumor.

Complications of cerebral angiography in children younger than 3 years of age

OBJECT

The therapeutic potential for cerebral angiography (CA) in young children is expanding. However, its use in this patient population is limited by presumed higher complication rates among children. Therefore, to improve the accuracy of counseling of the parents/guardians of these patients and to identify modifiable risk factors, the authors evaluated complications after CA in young children.

METHODS

The authors reviewed data for 309 consecutive cerebral angiograms obtained in 87 children younger than 36 months of age from 2004 to 2010 at a single institution. They analyzed demographics, diagnosis, angiographic findings, and complications.

RESULTS

The patient population comprised 40 boys and 47 girls; mean age was 14.36 months (range 1-36 months) and mean weight was 10.8 kg (range 3.7-21.0 kg). For 292 of the 309 procedures, intraarterial chemotherapy was administered; the remaining 17 procedures were for vascular malformations, stroke, tumor embolization, and intracranial hemorrhage. The rate of neurological complications was 0.0%. The rate of nonneurological complications was 2.9%: 7 cases of contrast allergy or bronchospasm, 1 groin hematoma (body weight 7 kg), and 1 transient femoral artery occlusion (body weight 10.8 kg). The rate of radiographic complications was 1.3%: 1 case of transient asymptomatic intraarterial dissection and 3 cases of asymptomatic vasospasm. Postprocedural MRI was performed for 33.3% of patients with no evidence of ischemia. There were no delayed complications. Mean follow-up time was 16.6 months. No association was found between complications and age, duration of anesthesia, number of vessels catheterized, size of the sheath, or diagnostic versus interventional procedures. Despite a trend toward a higher rate of complications for patients who weighed less than 15 kg, this finding was not significant (p = 0.35).

CONCLUSIONS

The rate of complications for CA in young children is comparable to rates reported for older children and lower than rates reported for adults. When appropriately indicated, CA should not be omitted from the therapeutic strategy of children younger than 36 months of age.

Superselective ophthalmic artery infusion of melphalan for intraocular retinoblastoma: preliminary results from 140 treatments

PURPOSE

To report our experience in superselective ophthalmic artery infusion of melphalan (SOAIM) for intraocular retinoblastoma.

METHODS

  From June 2008 to October 2010, 38 patients (18 women, 20 men; age range at first treatment, 7 months to 22 years) with 41 eyes with retinoblastoma were scheduled for SOAIM, for 17 newly diagnosed retinoblastomas Tumour, Node and Metastasis (TNM) 7th Edition 1a (n = 1), 1b (n = 1), 2a (n = 7), 2b (n = 4) and 3a (n = 4) and 24 retinoblastomas with partial remission/relapse TNM 7th Edition 1b (n = 13), 2a (n = 1) and 2b (n = 10). Eight patients (ten eyes) have been treated by SOAIM alone. Follow-up was 6-27 months in 28 patients (30 eyes).

RESULTS

Ophthalmic artery cannulation failed in two patients. Thirty-six patients underwent 140 treatments by internal (n = 112) or external (n = 28) carotid arteries. No major procedural complications occurred. Two patients have been lost to follow-up. Remaining 34 patients (37 eyes) had no metastatic disease. Four patients suffered permanent ocular complications: chorioretinal dystrophy (n = 2), ptosis (n = 1) and strabismus/exotropia (n = 1). Eight (22%) eyes in eight (24%) patients underwent enucleation: 7/16 (43%) newly diagnosed retinoblastomas and 1/22 (4.5%) retinoblastomas undergoing partial remission/relapse. For all treated eyes, Kaplan-Meier eye enucleation-free rates (K-M) were 85.4% (95% CI, 73.3-97.5%), 74.4% (95% CI, 57-91.8%) and still stable at 6, 12 months and 2 years, respectively. For eyes with partial remission/relapse, and eyes at presentation, K-M at 2 years were 95.5% (95% CI, 86.9-100%) and 45.6% (95% CI, 16.6-74.6%), respectively.

CONCLUSION

Superselective ophthalmic artery infusion of melphalan was safe and powerful, especially following other therapies. Superselective ophthalmic artery infusion of melphalan should be added to focal therapies spectrum. In selected cases, melphalan should be combined with other chemotherapeutic agents.

Hemodynamic instability induced by superselective angiography of the ophthalmic artery

Retinoblastoma is one of the most common ophthalmic neoplasms affecting children worldwide. Since its recent introduction, superselective ophthalmic artery injection of chemotherapy with melphalan has significantly reduced the need for enucleation in patients with advanced disease and also shown to have minimal adverse effects on visual acuity as compared to the conventional therapy. Although no severe complications resulting in strokes or deaths have been reported, this treatment modality is not without difficulties. In this case discussion, we describe an event that has occurred to several pediatric patients undergoing superselective angiography of the ophthalmic artery that may be due to an oculopulmonary type reflex causing significant hemodynamic instability and hypoxemia.

Intravenous and intra-arterial chemotherapy for retinoblastoma: what have we learned?

PURPOSE OF REVIEW

To review the recent literature on two methods of chemotherapy for retinoblastoma using intravenous versus intra-arterial route.

RECENT FINDINGS

In 1996, the era of intravenous chemotherapy (chemoreduction) for retinoblastoma was introduced with major centers providing published information on impressive tumor control, without the need for external beam radiotherapy or enucleation. Later reports heralded continued impressive long-term control, minimal systemic toxicities, likely prevention of pinealoblastoma (trilateral retinoblastoma), and reduction in numbers of germline mutation second cancers. There is no reported ophthalmic toxicity and no evidence of reduction in fertility with chemoreduction. In 2011, the era of intra-arterial chemotherapy was announced with several studies and three conflicting editorials in the literature. This technique requires a catheterization through the arterial tree from the femoral artery into the ophthalmic artery. Outstanding tumor control is achieved with only three cycles, but more-than-expected ocular ischemic events have been noted. Further improvements in this technique could minimize complications.

SUMMARY

Both intravenous and intra-arterial chemotherapy are powerful methods for retinoblastoma control. In addition to tumor control, intravenous chemotherapy protects from systemic metastasis and pinealoblastoma, minimizes long-term second cancers, and has few systemic and no ocular toxicities. Intra-arterial chemotherapy provides excellent tumor control for slightly more advanced eyes with retinoblastoma and, in addition, can be used to treat eyes that fail other methods. However, local ocular toxicities can be vision-threatening and long-term systemic toxicities are not yet understood.

Validating a nonhuman primate model of super-selective intraophthalmic artery chemotherapy: comparing ophthalmic artery diameters

PURPOSE

Superselective intraophthalmic artery chemotherapy (SSIOAC) is being used for treatment of retinoblastoma; however, the hemodynamic consequences and toxicities are not fully known. We developed a nonhuman primate (NHP) model of SSIOAC and reported our clinical observations. For validation, we compared ophthalmic artery (OA) diameters between NHPs and children (<6 years).

METHODS

Endovascular cannulation of the right OA was performed three times each in six adult male Rhesus macaques. Angiographic OA images were obtained and measured, and postmortem OAs were histologically sectioned and measured. Retrospectively, computed tomography (CT) and magnetic resonance (MR) angiography images of the head in children and adolescents (as an adult reference) were used to measure the OA luminal diameter at its origin.

RESULTS

The median angiographic diameter of treated NHP OA origins (n = 6) was 1.06 mm (range 0.94-1.56). Histologic measurements (8 of 12 NHP OAs) gave a median diameter of 1.09 mm (range 0.95-1.41). In 98 children (from 169 consecutive CT and MR angiography studies; median age 1.01 years, range 0.01-5.74), 186 OAs were measurable at the origin (median luminal diameter 1.28 mm, range 0.82-2.00; P = 0.16 for the angiographic NHP diameters versus pediatric cohort). Angiographic measurements of 34 OAs (of 20 consecutive studies of adolescents; median age 16.55 years, range 14.40-18.18) gave a median luminal diameter of 1.45 mm (origin, range 1.13-1.66; P < 0.0001, adolescent versus pediatric).

CONCLUSIONS

Measurements of the OA luminal diameter at its origin were similar between our NHP and pediatric cohort, validating our NHP model for testing both the hemodynamic consequences and toxicities of SSIOAC.

Pearls and pitfalls of intraarterial chemotherapy for retinoblastoma

Retinoblastoma is a deadly eye cancer in children, leading to death in 50%-70% of children in undeveloped nations who are diagnosed with it. This malignancy is the most common intraocular tumor in childhood worldwide. The good prognosis in developed nations is related to early detection and advanced treatments. With the advent of intraarterial chemotherapy, neurosurgeons have taken a central role in the treatment of this pediatric condition. Intraarterial chemotherapy is a novel treatment for retinoblastoma whereby chemotherapeutic agents are precisely delivered into the ophthalmic artery, minimizing systemic toxicity. This procedure has shown impressive results and has allowed a dramatic decrease in the rate of enucleation (eye removal) in advanced and refractory retinoblastoma. Recent reports have raised some concerns about the risk of ocular vasculopathy, radiation-related toxicity, and the potential for metastatic disease after intraarterial chemotherapy. In the authors' experience of more than 3 years, tumor control is excellent with globe salvage at 67% and vascular events less than 5%, mostly related to improvement in technique. The role of this novel approach in the management of retinoblastoma has yet to be defined. As more centers are adopting the technique, the topic will decidedly become the focus of intensive future research. In this paper, the authors review and discuss current data regarding intraarterial chemotherapy for retinoblastoma.

Retinoblastoma

Retinoblastoma is an aggressive eye cancer of infancy and childhood. Survival and the chance of saving vision depend on severity of disease at presentation. Retinoblastoma was the first tumour to draw attention to the genetic aetiology of cancer. Despite good understanding of its aetiology, mortality from retinoblastoma is about 70% in countries of low and middle income, where most affected children live. Poor public and medical awareness, and an absence of rigorous clinical trials to assess innovative treatments impede progress. Worldwide, most of the estimated 9000 newly diagnosed patients every year will die. However, global digital communications present opportunities to optimise standards of care for children and families affected by this rare and often devastating cancer. Parents are now leading the effort for widespread awareness of the danger of leucocoria. Genome-level technologies could make genetic testing a reality for every family affected by retinoblastoma. Best-practice guidelines, online sharing of pathological images, point-of-care data entry, multidisciplinary research, and clinical trials can reduce mortality. Most importantly, active participation of survivors and families will ensure that the whole wellbeing of the child is prioritised in any treatment plan.

Real-time ophthalmoscopic findings of superselective intraophthalmic artery chemotherapy in a nonhuman primate model

OBJECTIVE

To report real-time ophthalmoscopic findings during superselective intraophthalmic artery chemotherapy (SSIOAC) in a nonhuman primate model.

METHODS

Six adult male Rhesus macaques (Macacca mulatta) were randomly assigned to 1 of 2 treatment cohorts: melphalan (5 mg/30 mL) or carboplatin (30 mg/30 mL). Each animal underwent 3 separate SSIOAC procedures at 3-week intervals. Digital retinal images were obtained during each infusion. Intravenous fluorescein angiography was performed immediately after each procedure.

RESULTS

All SSIOAC procedures were successfully completed. Toxicities were equally distributed between drug cohorts. Systemic toxicities included mild bone marrow suppression in all animals and anorexia in 1. One animal had greater than 50% narrowing of the treated ophthalmic artery after its second infusion. All 18 procedures (100%) resulted in pulsatile optic nerve and choroid blanching, retinal artery narrowing, and retinal edema. Of the 18 procedures, retinal artery sheathing was found during 17 (94%), and retinal artery precipitates were seen in 10 (56%); choroidal hypoperfusion was seen by fluorescein angiogram in 18 (100%).

CONCLUSION

Real-time ophthalmic investigations are useful and, in our nonhuman primate model, indicate prevalent, acute ocular vascular toxicities during SSIOAC.

CLINICAL RELEVANCE

Real-time retinal imaging is feasible in a nonhuman primate model of SSIOAC. Application to SSIOAC in children may shed insight into reported vascular toxicities.

Regression of advanced group e retinoblastoma with intraarterial chemotherapy

PURPOSE

To report a case of regression of advanced retinoblastoma with intraarterial chemotherapy.

METHODS

A 25-month-old boy presented with extensive endophytic group E retinoblastoma with extensive vitreous seeds and total retinal detachment.

RESULTS

The patient underwent four sessions of intraarterial chemotherapy after which there was complete regression of vitreous seeds and near-complete calcification of the tumor.

CONCLUSION

Intraarterial chemotherapy is a novel treatment that is effective in selected cases of retinoblastoma. This technique allows selective delivery of chemotherapy to the involved tumor tissue with minimal systemic absorption.

Fluorescein angiographic findings after intra-arterial chemotherapy for retinoblastoma

PURPOSE

To evaluate fluorescein angiography (FA) findings after intra-arterial chemotherapy (IAC) for retinoblastoma.

DESIGN

Retrospective case series.

PARTICIPANTS

Twenty-four eyes of 24 patients.

INTERVENTION

Fifty-five IAC procedures for delivery of melphalan 5 mg and possible carboplatin 30 mg.

MAIN OUTCOME MEASURES

Vascular flow of iris, retina, and choroid after IAC.

RESULTS

All patients received melphalan 5 mg, whereas the first 6 patients also were treated with additional carboplatin 30 mg. The IAC was performed as primary treatment in 17 eyes and as secondary treatment (after systemic chemotherapy) in 7 eyes. Two patients also received external-beam radiotherapy before IAC. At presentation, FA revealed neovascularization of the iris (NVI) in 8 eyes, and after IAC, complete NVI regression was noted in 5 eyes (63%). After a mean follow-up of 13 months after IAC, FA depicted the main tumor with decreased fluorescence in 22 eyes (92%). After 55 ophthalmic artery catheterizations, retinal vascular abnormalities by FA were detected in 7 eyes (13%) and choroidal vascular abnormalities were detected in 6 eyes (11%). The retinal abnormalities included ophthalmic artery obstruction (n = 1), transient ophthalmic artery spasm (n = 1), central retinal artery obstruction (n = 1), branch retinal artery obstruction (n = 2), and peripheral retinal ischemia (n = 2). Additional retinal neovascularization was found in 1 patient. The choroidal abnormalities included sector (n = 5) or diffuse (n = 1) choroidal nonperfusion. New-onset iris neovascularization was found in 2 patients. Retinal vascular abnormalities were diagnosed after median of 1 month after the first IAC, whereas choroidal vascular abnormalities were found after median of 5 months after the first IAC.

CONCLUSIONS

Fluorescein angiography suggests that vascular perfusion to the retina and the choroid can be compromised after IAC for retinoblastoma. The most common vascular abnormality was choroidal sector or diffuse nonperfusion.

Enucleated eyes after failed intra-arterial infusion of chemotherapy for unilateral retinoblastoma: histopathologic evaluation of vitreous seeding

Selective intra-arterial chemotherapy (IAC) has been adopted by many ocular oncology centers to treat advanced intraocular retinoblastoma. In this report, we describe two patients with unilateral intraocular retinoblastoma and persistent vitreous seeding, who were treated with IAC after failed systemic chemotherapy. Despite multiple sessions and increasing dosage of drug delivery, vitreous seeding in these cases failed to respond to IAC, and ultimately both eyes were enucleated for tumor control. Based on the histopathologic findings in these two cases, IAC appears to have limitations in treating persistent vitreous seeding in eyes which have failed systemic chemotherapy. Possible causes for failure of IAC to treat persistent vitreous seeding include poor vitreous penetration, inactive state of tumor seeds within the avascular vitreous cavity, and chemotherapeutic drug resistance.

Minimal exposure (one or two cycles) of intra-arterial chemotherapy in the management of retinoblastoma

PURPOSE

To assess the efficacy of less than 3 cycles of intra-arterial chemotherapy (IAC) for retinoblastoma.

DESIGN

Retrospective, nonrandomized, interventional case series.

PARTICIPANTS

Eight patients.

INTERVENTION

Intra-arterial chemotherapy.

MAIN OUTCOME MEASURES

Tumor control and globe salvage.

RESULTS

Eight patients received fewer than 3 cycles of IAC for retinoblastoma because there was complete tumor control with no residual viable tumor (n = 7) or poor response (n = 1) with little hope that further therapy would benefit the patient. In 3 cases, additional vascular compromise precluded further IAC. The treatment was primary in 6 cases and secondary after failure of other treatment in 2 cases. The 8 eyes were classified (International Classification of Retinoblastoma) as group C (n = 2), group D (n = 3), group E (n = 1), and secondary treatment (n = 2). At initial examination, the main tumor showed a mean basal diameter of 16 mm, a thickness of 8.6 mm, vitreous seeds (n = 2), subretinal seeds (n = 6), and iris neovascularization (n = 1). Three patients were treated with a single cycle of IAC, and 5 patients were treated with 2 cycles of IAC. After IAC, complete tumor response was found in 7 eyes (88%) and partial response was found in 1 eye (13%). Over a mean of 13 months follow-up, there was intraretinal tumor recurrence (n = 1), subretinal seed recurrence (n = 1), and no case of vitreous seed recurrence. Globe salvage was achieved in 2 of 2 group C eyes (100%), 3 of 3 group D eyes (100%), 0 of 1 group E eye (0%), and 1 of 2 secondary treatment eyes (50%). Globe salvage was achieved in 6 of 8 eyes (75%), and 2 of 8 eyes (25%) required enucleation.

CONCLUSIONS

One or 2 cycles of IAC can be sufficient for selected eyes with group C or D retinoblastoma, with remarkable tumor control.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Retinoblastoma: Recent trends A mini review based on published literature

Retinoblastoma (RB) is the most common intraocular malignancy in children. Recently, there have been significant advances made in the molecular pathology and the management of the disease. Last decade has witnessed better understanding of the genetics of RB, the discovery of new tumor markers expressed by the RB tumors, the identification of high-risk histopathological factors following enucleation, and newer methods of treatment including periocular chemotherapy and superselective intraarterial chemotherapy. All these advances have translated in improved survival rates for the affected children, improved rates of eye salvage, and improved visual outcomes. This article briefly reviews these advances.Method of Literature Search: Literature on the Medline database was searched using the PubMed interface. The search strategy included MeSH and natural language terms using the keywords mentioned. Reference lists in retrieved articles and textbooks were also searched for relevant references.

Selective ophthalmic artery infusion of chemotherapy for advanced intraocular retinoblastoma: initial experience with 17 tumors

OBJECT

Retinoblastoma is the most common ocular neoplasm in children. Left untreated it spreads to the brain via the optic nerve. Traditional therapy is enucleation, and while this procedure is still the most common treatment worldwide, modern eye-preserving therapies can often spare the globe. However, patients with retinoblastoma often present in advanced stages of the disease when these globe-preserving strategies are often insufficient to prevent enucleation. In these challenging cases, direct infusion of chemotherapy into the ophthalmic artery has been attempted to achieve tumor control. The authors' aim in this study was to report on their initial experience with and clinical results for this approach.

METHODS

The authors prospectively collected data on all cases of retinoblastoma treated with selective intraophthalmic melphalan at Bascom Palmer Eye Institute. All cases were classified as International Intraocular Retinoblastoma Classification (IIRC) Group D or Reese-Ellsworth Group Vb, had not responded to aggressive multimodal therapy consisting of chemotherapy and focal consolidating laser therapy, and were pending enucleation. Using digital subtraction angiography, a microcatheter was navigated under roadmap guidance into the ophthalmic artery, and melphalan was infused over 40 minutes. Early in the series, patients were treated with 3 or 5 mg of melphalan, but after low response rates occurred all eyes were treated with 7.5 mg of melphalan. All patients were examined with funduscopy while under anesthesia 3 weeks after treatment and every 3 months thereafter. Patients with persistent disease were retreated with repeat infusions of melphalan.

RESULTS

Twenty-six procedures were performed to treat 17 tumors in 15 patients. Successful cannulation of the ophthalmic artery was achieved in all cases. The follow-up ranged from 3 to 12 months, with a mean of 8.6 months. Overall, 76% of the tumors responded to therapy and these cases were spared enucleation. The average number of treatments was 1.5 per tumor. Of the responders, 54% responded to a single dose of melphalan. Treatment with the higher dose of 7.5 mg up front was associated with a lower enucleation rate (0% vs 36%) as compared with the lower starting dose. Delayed vitreous hemorrhage occurred after 4 (15%) of 26 treatments, and these cases were treated with enucleation.

CONCLUSIONS

In this challenging group of advanced retinoblastomas refractory to aggressive multimodal therapy, virtually 100% of eyes are generally enucleated. In contrast, the authors' protocol of infusing melphalan directly into the ophthalmic artery led to a dramatic decrease in the enucleation rate to 23.5%. While it is now the treatment of choice for refractory retinoblastoma at their center, its role in less advanced disease remains to be elucidated.