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Lavasidis G, Strongylis M, Tzamalis A, Tsinopoulos I, Ntzani EE. Safety of intravitreal chemotherapy in the management of retinoblastoma: A systematic review of the literature. Crit Rev Oncol Hematol 2024; 200:104423. [PMID: 38897313 DOI: 10.1016/j.critrevonc.2024.104423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 06/05/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024] Open
Abstract
Intravitreal chemotherapy is used as a salvage therapy for retinoblastoma with persistent or recurrent vitreous seeding after primary treatment. To assess the safety of this technique, we conducted a systematic review of all studies reporting ocular toxicity data. Forty-eight trials involving 2751 eyes were included. The most common complications were cataract, retinal toxicity, and vitreous hemorrhage. However, severe and permanent adverse events were limited, while the risk of extraocular dissemination, a significant concern, was practically eliminated through preventive techniques. Globe salvage rates ranged from 29 % to 100 %. In conclusion, intravitreal chemotherapy seems to improve prognosis of eyes with advanced disease, with an acceptable safety profile. Nevertheless, most relevant studies are retrospective, and no randomized trials have been performed. Recognizing the challenges regarding the conduct of randomized studies for such a rare pediatric cancer, we believe that multicenter trials through international collaborations can significantly enhance the available information.
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Affiliation(s)
- Georgios Lavasidis
- Evidence-based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, Ioannina 45110, Greece; Department of Ophthalmology, Elpis General Hospital of Athens, Dimitsanas 7, Athens 11522, Greece; MSc Ocular Surgery, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki 54124, Greece.
| | - Mara Strongylis
- Department of Pediatrics, Evangelisches Krankenhaus Lippstadt, Wiedenbrücker Str. 33, Lippstadt 59555, Germany
| | - Argyrios Tzamalis
- MSc Ocular Surgery, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki 54124, Greece; 2nd Department of Ophthalmology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki 56403, Greece
| | - Ioannis Tsinopoulos
- MSc Ocular Surgery, School of Medicine, Aristotle University of Thessaloniki, University Campus, Thessaloniki 54124, Greece; 2nd Department of Ophthalmology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki 56403, Greece
| | - Evangelia E Ntzani
- Evidence-based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, Ioannina 45110, Greece; Center for Evidence Synthesis in Health, Brown University School of Public Health, 121 South Main St., Providence, RI 02912, USA; Department of Epidemiology, Brown University School of Public Health, 121 South Main St., Providence, RI 02912, USA
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Rajan RP, Kim U, Maitray A, Jena S, Sen S. A Rare Case of Acute Hemorrhagic Retinopathy Following Intravitreal Melphalan Injection for Persistent Vitreous Seeds in Retinoblastoma. JOURNAL OF VITREORETINAL DISEASES 2022; 6:155-157. [PMID: 37008661 PMCID: PMC9976017 DOI: 10.1177/24741264211024147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: This report describes a case of acute occlusive hemorrhagic complication after intravitreal melphalan for vitreous seeds in retinoblastoma. Methods: A case report is presented. Results: Intravitreal melphalan has been used extensively for vitreous seeds in retinoblastoma. Although melphalan is relatively safe at optimal doses, it can sometimes cause inadvertent complications like hemorrhagic events if the drug is administered close to the retina or in more pigmented eyes. We report a case of a 5-month-old patient with bilateral retinoblastoma who underwent enucleation of the right eye and 2 intravitreal melphalan injections in the left eye (20 µg/0.02 mL) at a 1-month interval for persistent vitreous seeds. After the second injection, there was a sudden decrease in the child’s visual acuity in the left eye, and the retina showed multiple intraretinal hemorrhages and diffuse chorioretinal atrophy. Conclusion: Intravitreal melphalan may cause acute hemorrhagic complications after intravitreal use for retinoblastoma seeds, especially in pigmented eyes.
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Affiliation(s)
- Renu P. Rajan
- Department of Retina & Vitreous, Aravind Eye Hospital, Madurai, India
| | - Usha Kim
- Department of Orbit and Oculoplasty, Aravind Eye Hospital, Madurai, India
| | - Aditya Maitray
- Department of Retina & Vitreous, Aravind Eye Hospital, Madurai, India
| | - Soumya Jena
- Department of Retina & Vitreous, Aravind Eye Hospital, Madurai, India
| | - Sagnik Sen
- Department of Retina & Vitreous, Aravind Eye Hospital, Madurai, India
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Rishi P, Attiku Y, Manchegowda PT, Agarwal A, Sharma M. Vitreous Seed Classification and Regression Patterns in Eyes With Retinoblastoma. JOURNAL OF VITREORETINAL DISEASES 2021; 5:121-129. [PMID: 37009089 PMCID: PMC9979059 DOI: 10.1177/2474126420951980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Purpose: This work subclassifies retinoblastoma vitreous seeds and evaluates the efficacy, regression patterns, and adverse effects of combination intravitreal melphalan and topotecan chemotherapy for resistant and recurrent vitreous seeds. Methods: A retrospective review of medical records was conducted of patients with retinoblastoma and resistant or recurrent vitreous seeds who were treated with intravitreal melphalan and topotecan injections from August 2014 to July 2018. Main outcome measures included regression pattern, time for regression, time for recurrence of seeds, treatment outcomes, and ocular toxicity. Results: Nineteen eyes received 138 intravitreal injections over 74 treatment sessions (mean, 7.26 injections per eye); vitreous seeds regressed in 18 eyes. Of cloud vitreous seeds, curvilinear (n = 2) and sphero-linear (n = 2) subtypes were observed. During regression, some sphere seeds showed an intermediary streak-like pattern and took longer to regress (mean, 11.13 ± 14.05 months and 11.67 ± 8.62 injections) than those without the intermediary streak-like pattern (mean, 3.55 ± 2.57 months and 4.2 ± 1.87 injections). Mean follow-up was 34.87 ± 21.09 months (median, 35 months; range, 11-96 months). Anterior segment toxicity was seen in 10 (53%) eyes and posterior segment toxicity in 5 (26%) eyes. Kaplan-Meier survival estimates for globe salvage at 2 years was 94% and 73% at 5 years. Kaplan-Meier survival for vitreous seed–free status was 94% at 2 years and 65% at 5 years. Conclusions: An expanded vitreous seed classification system that further subcategorizes hitherto unrecognized vitreous seed morphology is needed. An intermediate streaking process results in a prolonged regression time for sphere vitreous seeds.
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Affiliation(s)
- Pukhraj Rishi
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Yamini Attiku
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Pradeep T. Manchegowda
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Ashutosh Agarwal
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Minal Sharma
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
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4
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Bogan CM, Pierce JM, Doss SD, Tao YK, Chen SC, Boyd KL, Liao A, Hsieh T, Abramson DH, Francis JH, Friedman DL, Richmond A, Daniels AB. Intravitreal melphalan hydrochloride vs propylene glycol-free melphalan for retinoblastoma vitreous seeds: Efficacy, toxicity and stability in rabbits models and patients. Exp Eye Res 2021; 204:108439. [PMID: 33444583 PMCID: PMC8117559 DOI: 10.1016/j.exer.2021.108439] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/15/2020] [Accepted: 01/05/2021] [Indexed: 11/22/2022]
Abstract
The use of intravitreal chemotherapy has revolutionized the treatment of advanced intraocular retinoblastoma, as intravitreal melphalan has enabled difficult-to-treat vitreous tumor seeds to be controlled, leading to many more eyes being saved. However, melphalan hydrochloride (MH) degrades rapidly in solution, increasing logistical complexity with respect to time between medication preparation and administration for intravitreal administration under anesthesia for retinoblastoma. A new propylene glycol-free melphalan (PGFM) formulation has greater stability and could therefore improve access and adoption of intravitreal chemotherapy, allowing more children to retain their eye(s). We compared the efficacy and toxicity of both formulations, using our rabbit xenograft model and clinical patient experience. Three weekly 12.5 μg intravitreal injections of MH or PGFM (right eye), and saline (left eye), were administered to immunosuppressed rabbits harboring human WERI-Rb1 vitreous seed xenografts. Residual live cells were quantified directly, and viability determined by TUNEL staining. Vitreous seeds were reduced 91% by PGFM (p = 0.009), and 88% by MH (p = 0.004; PGFM vs. MH: p = 0.68). All residual cells were TUNEL-positive (non-viable). In separate experiments to assess toxicity, three weekly 12.5 μg injections of MH, PGFM, or saline were administered to non-tumor-bearing rabbits. Serial electroretinography, optical coherence tomography (OCT) and OCT-angiography were performed. PGFM and MH both caused equivalent reductions in electroretinography amplitudes, and loss of retinal microvasculature on OCT-angiography. The pattern of retinal degeneration observed on histopathology suggested that segmental retinal toxicity associated with all melphalan formulations was due to a vitreous concentration gradient-effect. Efficacy and toxicity were assessed for PGFM given immediately (within 1 h of reconstitution) vs. 4 h after reconstitution. Immediate- and delayed-administration of PGFM showed equivalent efficacy and toxicity. In addition, we evaluated efficacy and toxicity in patients (205 eyes) with retinoblastoma vitreous seeds, who were treated with a total of 833 intravitreal injections of either MH or PGFM as standard of care. Of these, we analyzed 118 MH and 131 PGFM monotherapy injections in whom serial ERG measurements were available to model retinal toxicity. Both MH and PGFM caused reductions in electroretinography amplitudes, but with no statistical difference between formulations. Comparing those patient eyes treated exclusively with PGFM versus those treated exclusively with MH, efficacy for tumor control and globe salvage was equivalent (PGFM vs. MH: 96.2% vs. 93.8%, p = 0.56), but PGFM-treated eyes received fewer injections than MH-treated eyes (average 3.2 ± 1.9 vs. 6.4 ± 2.1 injections, p < 0.0001). Taken together, these rabbit experiments and our clinical experience in retinoblastoma patients demonstrate that MH and PGFM have equivalent efficacy and toxicity. PGFM was more stable, with no decreased efficacy or increased toxicity even 4 h after reconstitution. We therefore now use PGFM over traditional MH for our patients for intravitreal treatment of retinoblastoma.
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Affiliation(s)
- Carley M Bogan
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Janene M Pierce
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie D Doss
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yuankai K Tao
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Sheau-Chiann Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelli L Boyd
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Albert Liao
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Terry Hsieh
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Debra L Friedman
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ann Richmond
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA; Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA; Program in Cancer Biology, Vanderbilt University, Nashville, TN, USA
| | - Anthony B Daniels
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA; Program in Cancer Biology, Vanderbilt University, Nashville, TN, USA; Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Berry JL, Kim ME, Pefkianaki M, Reid M, Shah R, Jubran R, Kim JW. Intravitreal Melphalan for Retinoblastoma: The Impact of Toxicity on Recurrence and Ultimate Globe Salvage. Ocul Oncol Pathol 2021; 6:388-394. [PMID: 33447588 DOI: 10.1159/000509080] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/01/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction Intravitreal melphalan (IVM) has emerged as an efficacious treatment for vitreous seeding in retinoblastoma. Although rarely severe, IVM-related toxicity may be treatment limiting. There is paucity of data on the impact of IVM toxicity on new tumor formation and ultimate globe salvage. Objectives To investigate whether the grade of retinal toxicity post-IVM impacts retinal and seeding tumor recurrence, as well as the overall ability to salvage the eye. Methods A single-institution retrospective chart review was performed on 47 eyes of 42 patients who received systemic intravenous chemotherapy followed by IVM as salvage treatment for persistent or recurrent vitreous seeding. Chorioretinal toxicity was graded from 0 to 5. Results Toxicity grade was inversely associated with the risk of recurrence, where a one-unit increase in toxicity grade correlated with nearly a 54% reduction in the odds of tumor recurrence (OR 0.46 [0.25-0.84], p = 0.01). Similarly, toxicity grade was related to enucleation, where a one-unit increase in toxicity grade was associated with a 31% reduction in the odds of undergoing enucleation (OR 0.69 [0.40-1.18], p = 0.17). Conclusions While retinoblastoma therapy aims to limit toxicity, especially visually significant toxicity, eyes with higher grades of post-IVM toxicity are less likely to have retinal and seeding tumor recurrence.
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Affiliation(s)
- Jesse L Berry
- The Vision Center at Children's Hospital Los Angeles, Los Angeles, California, USA.,USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mary E Kim
- The Vision Center at Children's Hospital Los Angeles, Los Angeles, California, USA.,USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Maria Pefkianaki
- The Vision Center at Children's Hospital Los Angeles, Los Angeles, California, USA.,USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Mark Reid
- The Vision Center at Children's Hospital Los Angeles, Los Angeles, California, USA.,USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Rachana Shah
- Division of Oncology, Cancer and Blood Diseases Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Rima Jubran
- Division of Oncology, Cancer and Blood Diseases Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jonathan W Kim
- The Vision Center at Children's Hospital Los Angeles, Los Angeles, California, USA.,USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Rishi P. Commentary: Current standards in retinoblastoma care. Indian J Ophthalmol 2020; 68:2367. [PMID: 33120618 PMCID: PMC7774166 DOI: 10.4103/ijo.ijo_3198_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Pukhraj Rishi
- Truhlsen Eye Institute, University of Nebraska Medical Centre, Omaha, NE, USA
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