Supraselective intra-arterial chemotherapy: evaluation of treatment-related complications in advanced retinoblastoma

Abstract

Purpose: The purpose of this study is to report the complication profile and safety evaluation of supraselective intra-arterial melphalan chemotherapy in children undergoing treatment with advanced retinoblastoma.

Methods: Twelve eyes of 10 children with advanced retinoblastoma (Reese-Ellsworth Group Vb or International Classification Group D) were treated with supraselective intra-ophthalmic artery infusion of melphalan. Eleven eyes of nine children had previously failed traditional management with systemic chemotherapy and laser ablation and underwent intra-ophthalmic artery infusion of melphalan as an alternative to enucleation. Serial ophthalmic examinations, retinal photography, and ultrasonographic imaging were used to evaluate treatment regime.

Results: Ophthalmic artery cannulation was successfully performed in 12 eyes of 10 patients (total 16 times). Striking regression of tumor, subretinal and vitreous seeds were seen early in each case. No severe systemic side effects occurred. Grade III neutropenia was seen in one patient. No transfusions were required. Three patients developed a vitreous hemorrhage obscuring tumor visualization. One patient developed periocular edema associated with inferior rectus muscle inflammation per orbital MRI. This same patient had scattered intraretinal hemorrhages and peripapillary cotton wool spots consistent with a Purtscher's-like retinopathy that resolved spontaneously. At the 6-month follow-up examination, nine eyes had no evidence of tumor progression, whereas three eyes were enucleated for tumor progression. In each enucleated case, viable tumor was identified on histopathologic examination.

Conclusions: Ophthalmic intra-arterial infusion with melphalan is an excellent globe-conserving treatment option in advanced retinoblastoma cases with minimal systemic side effects. Local toxicities include microemboli to the retina and choroid (1/12, 8%), vitreous hemorrhage (3/12, 25%), and myositis (1/12, 8%). Enucleation remained a definitive treatment for tumor progression in 3 of 12 eyes in this small case series with limited follow-up. Further studies are necessary to establish the role of supraselective intra-arterial melphalan chemotherapy for children with retinoblastoma.

Keywords: intra-arterial chemotherapy; melphalan; retinoblastoma.

Figure 1

Patient #8 diagnosed with unilateral advanced reese-ellsworth Group Vb or International Classification Group D retinoblastoma previously treated with systemic chemoreduction and focal consolidative treatment, then periocular carboplatin injections without tumor regression. As a salvage therapy, intra-arterial melphalan infusion at 5 mg was performed, which lead to tumor regression. A) At presentation. B) After systemic chemoreduction and focal laser photocoagulation. C) Five months after a single infusion of melphalan at 5-mg dose.

Figure 2

Patient #1 presented with Reese-Ellsworth Group Vb or International Classification Group D retinoblastoma initially treated with systemic multiagent chemoreduction (carboplatin, vincristine, etoposide, and cyclosporine) with focal laser photocoagulation and subsequently with six periocular carboplatin injections. Even with this aggressive treatment, the tumor continued to progress. The patient then underwent intra-arterial melphalan infusion as salvage therapy at the 3-mg dose and then at the 7.5-mg dose. Subsequently, the patient developed a vitreous hemorrhage obscuring tumor visualization. Echographic evaluation demonstrated tumor progression, and the patient underwent definitive therapy with enucleation. A) At presentation. B) Before first melphalan infusion (3-mg dose). C) Before second melphalan infusion (7.5 mg).

Figure 3

Patient #10 treated primarily with single, high dose (7.5 mg) intra-arterial infusion of melphalan. A) Before treatment. B) One week after treatment. C) Five months after treatment. In this case, intra-arterial melphalan treatment resulted in complete resolution of the tumor by 1 month posttreatment and no evidence of progression at 5 months. At 1-week follow-up, the patient developed periocular swelling, and an MRI of orbits was obtained showing inferior rectus muscle inflammation. On dilated funduscopic examination, peripapillary cotton wool spots and scattered intraretinal hemorrhages were noted consistent with Purtscher’s-like retinopathy in the treated eye. On follow-up examinations, these findings resolved spontaneously.