Stereotactic Gamma Knife® Radiosurgery of Intraocular Retinoblastoma: Six-Year Experience

Abstract

Background External beam radiotherapy for resistant retinoblastoma is now seen as a last resort to saving the eye because of the risk of severe side effects: secondary cancers and cosmetic problems of orbital bone growth retardation. To reduce such complications, treatment modalities have shifted towards new radiation therapy techniques. No information on single fraction Gamma Knife® radiosurgery (GKRS) for intraocular retinoblastoma exists. Materials and methods Eighteen children (19 eyes) with retinoblastoma were treated with GKRS. The mean age at the time of treatment was 35 months (from 12 to 114 months). Before GKRS, all routes of chemotherapy delivery were held in all cases. The eligibility criteria for GKRS were retinoblastomas not amenable either to systemic or local chemotherapy and local ophthalmological treatment, retinoblastomas too large for conventional local methods, and inability to perform intraarterial chemotherapy. Conventional external beam radiotherapy was excluded in the presented cases, given the possible complications mentioned above. In every case, eye removal was suggested to the child's parents, but they flatly refused. GKRS was proposed as the last chance to save the eye (in four cases, it was performed on the only eye). The median prescribed dose was 22 Gy (interquartile range [IQR]: 18-35 Gy), and the median prescribed isodose was 50% (IQR: 36-90%). Results Local control was achieved in 79% of cases (complete tumor regression in 69%, incomplete regression in 10%). Two eyes (10.5%) could not be preserved and had to be enucleated due to the tumor recurrence. Two eyes (10.5%) developed secondary complications (total vitreous hemorrhage, retinal detachment, and iris neovascularization), making adequate tumor control nearly impossible. Overall, 15 eyes (79%) were preserved, and four eyes (21%) were enucleated after GKRS with no signs of tumor recurrence and metastasis in the mean follow-up of 41 months. No acute radiation side effects occurred in any patient after GKRS. Ten children (10 eyes, 53%) were diagnosed with vitreous hemorrhage from mild to severe. Three eyes presented with optic neuropathy one year after GKRS, and four eyes developed retinopathy. Radiation-induced cataract occurred in two eyes. There were no cases of secondary glaucoma or keratopathy in our study. All patients and eyes treated by GKRS were stable within 41 months (from seven to 74 months). Conclusions Single fraction Gamma Knife® radiosurgery may be a reasonable salvage treatment for resistant and recurrent retinoblastoma as an alternative approach to enucleation in selected cases. GKRS should be considered in retinoblastoma management.

Keywords: eye salvage treatmemt; gamma-knife; radiosurgery; radiotherapy; retinoblastoma.

Figure 1. Massive vitreous lesion before GKRS

GKRS - Gamma Knife® radiosurgery

Figure 2. Treatment planning

Figure 3. Incomplete tumor regression three months after GKRS

GKRS - Gamma Knife® radiosurgery

Figure 4. Incomplete tumor regression eight months after GKRS

GKRS - Gamma Knife® radiosurgery

Figure 5. Complete tumor regression 10 months after GKRS

GKRS - Gamma Knife® radiosurgery

Figure 6. Large retinal tumor before GKRS

GKRS - Gamma Knife® radiosurgery

Figure 7. Treatment planning

Figure 8. Incomplete tumor regression three months after GKRS

GKRS - Gamma Knife® radiosurgery

Figure 9. Complete tumor regression one year after GKRS

GKRS - Gamma Knife® radiosurgery