First-line intra-arterial versus intravenous chemotherapy in unilateral sporadic group D retinoblastoma: evidence of better visual outcomes, ocular survival and shorter time to success with intra-arterial delivery from retrospective review of 20 years of treatment

Abstract

PurposeThe introduction of intra-arterial chemotherapy (IAC) as salvage treatment has improved the prognosis for eye conservation in group D retinoblastoma. The aim of this study was to compare the outcomes of consecutive patients with advanced unilateral disease treated with either first-line intravenous chemotherapy (IVC) or first-line IAC.DesignThis is a retrospective mono-centric comparative review of consecutive patients.PatientsSporadic unilateral retinoblastoma group D cases treated conservatively at Jules-Gonin Eye Hospital and CHUV between 1997 and 2014. From January 1997 to August 2008, IVC, combined with focal treatments, was the primary treatment approach. From September 2008 to October 2014, IAC replaced IVC as first-line therapy.Methods48 patients met the inclusion criteria, receiving only either IAC or IVC as primary treatment modality.ResultsOutcomes of 23 patients treated by IVC were compared with those of 25 treated by IAC; mean follow-up was 105.3 months (range 29.2–218.6) and 41.7 months (range 19.6–89.5), respectively. Treatment duration was significantly shorter in the IAC group (p<0.001). Ten eyes in the IVC group underwent enucleation. Recordable visual acuity of the salvaged eyes was significantly better in the IAC group (0.9 vs 1.4 logarithm of the minimum angle of resolution, p<0.01). No extraocular disease, metastases or long-term systemic complications were observed in either group.ConclusionsThe difference in the time frame between treatment groups had an impact on the availability of intravitreal chemotherapy treatment. Despite this, the results reported here imply that eyes treated with first-line IAC will have shorter treatment period, better ocular survival and visual acuity than first-line IVC.

Long‐term outcomes of Group D retinoblastoma eyes during the intravitreal melphalan era

“…Using systemic chemotherapy alone, approximately half (48%) of Group D eyes were salvaged in this series, which is consistent with previous reports of Group D eyes treated with primary intravenous chemotherapy . Several recent studies have documented significantly higher globe salvage rates for Group D eyes treated with intraarterial chemotherapy . Salvage rates in Group D eyes using intraarterial chemotherapy has been reported to range from 68 to 90% with several factors including subretinal and vitreous seeding playing a significant role in relapse .…”

“…8,10 Several recent studies have documented significantly higher globe salvage rates for Group D eyes treated with intraarterial chemotherapy. 12,13 Salvage rates in Group D eyes using intraarterial chemotherapy has been reported to range from 68 to 90% with several factors including subretinal and vitreous seeding playing a significant role in relapse. 6,16,[44][45][46] The results of our retrospective study suggest that the success rate for Group D eyes following intravenous chemotherapy can now be augmented in the era of intravitreal melphalan injections.…”

“…Thus, despite an era of successful chemotherapeutic strategies using chemoreduction combined with local consolidation, relapse remained common and refractory disease with subretinal or vitreous seeding resulted in secondary enucleation or treatment with external beam radiation therapy (EBRT). 9 Our center 10 and others 8,[11][12][13][14][15][16][17][18] reported success rates of 45-50% in salvaging Group D eyes with systemic chemoreduction, 8,10 while intraarterial chemotherapy has resulted in success rates of 68-90% for advanced Group D eyes. EBRT was still used as second-line salvage therapy to treat refractory vitreous seeding.…”

Feasibility and results of an intraarterial chemotherapy program for the conservative treatment of retinoblastoma in Argentina

“…Visual outcomes are seldom reported for eyes treated with OAC or intravitreous chemotherapy. Even though visual acuity, on average, in our population was encouraging compared to patients treated with unilateral retinoblastoma, an evaluation reporting visual outcomes in greater detail should be undertaken to arrive at definitive conclusions. Our results in group D eyes need to be improved despite the advances seen with the use of OAC.…”

Retinoblastoma Management: Advances in Chemotherapy

“…Currently, the common indications for IAC in retinoblastoma patients include unilateral retinoblastoma that cannot be halted by local treatments alone (e.g., cryotherapy or laser photocoagulation) and advanced unilateral retinoblastoma (such as group D and E based on the ICRB) [30]. Several studies had previously reported the following advantages of using IAC in patients with group D retinoblastoma: better eye conservation rates and greater visual acuity compared to systemic chemotherapy, shorter treatment period and ability to repeat the therapy several times using multiple agents without endangering the patients' life and vision [28,38]. It is also noteworthy to mention that IAC can save naïve eyes with advanced retinoblastoma from enucleation particularly when subretinal seeding is present (2 year ocular survival rate of 83%) [39].…”