Intracameral Chemotherapy (Melphalan) for Aqueous Seeding in Retinoblastoma: Bicameral Injection Technique and Related Toxicity in a Pilot Case Study

Abstract

Background: The anterior chamber has been shown by pharmacokinetic studies to represent a sanctuary never achieving a tumoricidal dose with the present administration routes, such as systemic, intra-arterial, or intravitreal injections. Method: A novel intracameral chemotherapy technique is described to control aqueous seeding in a pilot unilateral group E retinoblastoma case with primary aqueous seeding. Anterior segment toxicity was carefully monitored. Results: Control of the retinal tumor and vitreous seeding was achieved by intra-arterial and intravitreal chemotherapies. Sterilization of the aqueous was achieved after a first cycle of 7 melphalan injections in the anterior chamber, but relapse was noted 3.5 months later. This relapse was finally controlled with a second cycle of 6 intracameral injections targeting the posterior chamber. Corneal endothelial cell density remained stable over the injection period. Heterochromia and a progressive cataract developed, which required cataract surgery. At 5 years' follow-up, the patient is tumor free with normal vision (20/20 in both eyes), full binocularity, and no metastasis. Conclusions: The present bicameral injection technique appears to be safe and effective with limited toxicity. Melphalan-induced side effects were noted on the iris and lens but with no impact on the final visual function.

Conservative management of retinoblastoma: Challenging orthodoxy without compromising the state of metastatic grace. “Alive, with good vision and no comorbidity”

“…The latter fully surrendered only to intravitreal chemotherapy, which became available in 2012 following the description of a safety-enhanced injection technique (Munier et al, 2012a). Aqueous seeding, the very last intra-ocular sanctuary to resist virtually all available treatment modalities, became manageable only since 2015 with the description of a technique adapted to safely inject into the anterior and posterior chambers (Munier et al, 2015), now successfully implemented in the current management of aqueous disease (Munier et al, 2017a(Munier et al, , 2018. To date, the appropriate combination of all these modalities has enabled unprecedented eye survival rates, even for advanced retinoblastoma, contributing at the same time to the eradication of external beam irradiation in the treatment of intraocular retinoblastoma without jeopardizing patient survival.…”

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

“…Several authors have subsequently published clinical series with highly encouraging results and low rates of complications . The high success rates in treating vitreous seeding have overall been so encouraging that lower dose regimens, multidrug regimens, and a pilot study of intracameral injection of chemotherapy have been described . IVC holds the potential for increasing the rate of event‐free globe survival in patients who otherwise face as high as a 50% risk of enucleation or exposure to radiation therapy.…”

“…[21][22][23][24][25][26][27][28][29][30][31][32][33][34] The high success rates in treating vitreous seeding have overall been so encouraging that lower dose regimens, 35 multidrug regimens, 25 and a pilot study of intracameral injection of chemotherapy have been described. 36 IVC holds the potential for increasing the rate of event-free globe survival in patients who otherwise face as high as a 50% risk of enucleation or exposure to radiation therapy.…”

Conservative treatment of diffuse infiltrating retinoblastoma: optical coherence tomography-assisted diagnosis and follow-up in three consecutive cases

“…Actually, more than half of the cases are misdiagnosed 4. To date, except for four cases of a variant subtype, namely diffuse anterior rb salvaged with intracameral chemotherapy6 or plaque brachytherapy,7 previously published cases of diffuse infiltrating rb have always been managed with enucleation 1 3 5 8…”