Intra-arterial chemotherapy in retinoblastoma - A paradigm change

Abstract

Intra-arterial chemotherapy (IAC), also known as superselective ophthalmic artery chemotherapy or chemosurgery, is currently widely accepted as one of the primary treatment modalities for intraocular retinoblastoma worldwide. Following the introduction of the technique in 1998, IAC has evolved over the past decades to be safer and more effective. Accumulated evidence shows that IAC is more effective in providing eye salvage in group D and E retinoblastoma as compared to conventional systemic intravenous chemotherapy (IVC). In contrast to IVC, IAC has the added benefits of reduced overall treatment duration and minimal systemic toxicity. This review provides a comprehensive update on the history, technique, indications, contraindications, and outcome of IAC. We have also identified the strengths, weaknesses, opportunities and threats (SWOT analysis) of the technique in this review.

Keywords: Retinoblastoma; chemosurgery; intra-arterial chemotherapy; selective ophthalmic artery chemotherapy; superselective ophthalmic artery chemotherapy.

Figure 1

Selective ophthalmic artery chemotherapy is performed by passing the catheter via ICA through the femoral artery into the OA ostium. (route marked in blue) Alternate route is catheterization of MMA via ECA and IMA. (route marked in green). In Japanese technique, ICA distal to OA ostium is occluded with balloon. (CCA=common carotid artery; ECA= external carotid artery; ICA=internal carotid artery; IMA- internal maxillary artery; MMA= middle meningeal artery; OA= ophthalmic artery; LA= lacrimal artery; SOA= supraorbital artery)

Figure 2

(a) Fundus photograph of a 10-month-old Caucasian infant showing solitary exophytic macular retinoblastoma with focal subretinal seeds and subretinal fluid in the right eye (OD), classified as group C. (b) B-scan ultrasonography confirming a calcified intraocular measuring 7.11 mm in thickness. After receiving three sessions of IAC, (c) the tumor is completely regressed (Type 1) with resolution of subretinal fluid and (d) the tumor has reduced to 3.71 mm thickness

Figure 3

(a) Fundus photograph of a 6-month-old Caucasian infant showing solitary endophytic retinoblastoma with diffuse subretinal and vitroeus seeds in the left eye (OS). (b) B-scan ultrasonography confirming a large calcified intraocular mass occupying >50% of globe and measuring 12.20 mm thickness. After receiving four sessions of IAC, (c) tumor is regressed (Type 3) with calcified subretinal and vitreous seeds and (d) the tumor has reduced to 5.00 mm thickness, with visible partial posterior vitreous detachment

Figure 4

(a) Fundus photograph of a 7-month-old Chinese infant showing large, exophytic, retinoblastoma in the OS with retinal detachment, subretinal seeds and no view of optic disc, and (b) following two sessions of IAC, the tumor is completely regressed (Type 1) and the optic nerve (arrow) is visible. (c) Fundus photograph of a 9-month-old Indian infant showing large, exophytic, retinoblastoma in OD with total retinal detachment (arrow), subretinal seeds, and no view of optic disc, and (d) following three sessions of IAC, the tumor is regressed (Type 3) and there is complete resolution of subretinal fluid with visible optic disc

Figure 5

(a) Fundus photograph of a 2-year-old Caucasian infant showing large, exophytic/endophytic (group D) with vitreous and subretinal seeds, overlying the optic nerve in OS. (b) B-scan ultrasonography confirming a large calcified intraocular mass measuring 10.74 mm thickness. After receiving four sessions of IAC, (c) the tumor is regressed (Type 3) and located away from the optic disc with flat fovea and potential for vision. (d) The tumor has reduced to 4.81 mm thickness

Figure 6

(a) Fundus picture showing tumor and vitreous seeds’ recurrence in OD post IAC four sessions in a group D eye (arrow with dotted lines) of a 2-year-old Chinese boy. (b) After rescue IAC two sessions, tumor and seeds completely regressed. (c) Tumor recurrence with vitreous clouds after six cycles of systemic chemotherapy in a 3-year-old Indian boy in OS. (d) Following three sessions of IAC, tumor is totally calcified and vitreous is clear

Figure 7

(a) Forehead hyperemia along the distribution of supraorbital artery and blepheroptosis in a 6-month-old Chinese girl after first session of IAC in OD. (b) Ipsilateral alopecia in a 2-year-old Chinese boy following IAC in OD

Figure 8

(a) Group D unilateral RB in a 2 year-old Indian boy with total retinal detachment in OS. (b) After three sessions of IAC, the tumor and retinal detachment have completely resolved, but ophthalmic artery occlusion has lead to optic nerve atrophy and diffuse retinal atrophy with arteriolar narrowing

Figure 9

SWOT analysis of IAC