Incidence of New Tumor Formation in Patients with Hereditary Retinoblastoma Treated with Primary Systemic Chemotherapy: Is There a Preventive Effect?

PURPOSE

To report the incidence of new tumor formation in hereditary retinoblastoma patients treated with primary systemic chemotherapy.

DESIGN

Noncomparative retrospective case series.

PARTICIPANTS

Fifty-eight consecutive patients with hereditary retinoblastoma treated with primary systemic chemotherapy.

METHODS

The charts of 58 consecutive patients with hereditary retinoblastoma treated between January 1996 and August 2005 were reviewed. Data extracted included gender, age at diagnosis, family history of retinoblastoma, laterality of disease, tumors per eye, Reese-Ellsworth grouping of affected eyes, starting and ending dates for chemotherapy, number of cycles of chemotherapy, chemotherapy regimen, need for external beam radiotherapy and/or enucleation, and development and location (macula, midzone, and periphery) of new tumors after the start of systemic chemotherapy.

MAIN OUTCOME MEASURE

New tumor formation after treatment with primary systemic chemotherapy.

RESULTS

Of the 58 patients, 48 had bilateral involvement at diagnosis. Median age at diagnosis was 6.6 months. Thirteen patients had a positive family history. Of the eyes with tumor (n = 106) at diagnosis, 52 (49%) were in Reese-Ellsworth groups I to III, whereas 54 (51%) were in group IV or V. Seven patients (12%) with a median age of 1.6 months at diagnosis formed 36 new tumors in 11 eyes after the start of chemotherapy. Median time from initiation of chemotherapy to detection of the first new tumor was 3 months (range, 1-15). Cumulative incidence of new tumor formation at 2 years was 10+/-3%. An age of <6 months at diagnosis, family history of retinoblastoma, and Reese-Ellsworth grouping of I to III were found to correlate significantly with an increased incidence of new tumor formation (P<0.001, P<0.001, and P = 0.021, respectively). Median follow-up for all patients was 5 years (range, 1-10.1).

CONCLUSION

New tumors continue to form in patients with hereditary retinoblastoma despite treatment with primary systemic chemotherapy. Younger patients and those with a positive family history are more likely to have new tumors formed. However, chemotherapy may impact small previously undetected lesions by slowing their growth and facilitating later focal consolidation.

Low-Dose Cyclophosphamide and Interferon Alfa 2a for the Treatment of Capillary Hemangioma of the Orbit

PURPOSE

To report the use of a combination of low-dose cyclophosphamide and interferon alfa 2a (IFNalpha2a) for the treatment of orbital juvenile capillary hemangioma.

DESIGN

Retrospective case series.

PARTICIPANTS

Five patients with juvenile capillary hemangiomas of the orbit.

METHODS

Five patients with a median age of 9 weeks presented with a rapidly enlarging orbital mass. Two patients also had involvement of the upper eyelid obstructing the visual axis. Patients underwent biopsy to confirm the diagnosis before starting combination therapy with low-dose oral cyclophosphamide (10 mg/kg per day for 3 days repeated every 2 weeks) and subcutaneous IFNalpha2a (3 million units/m2 per day once daily) for a maximum treatment time of 4 to 6 months. Patients underwent serial ophthalmic, hematologic, and neurologic evaluations.

MAIN OUTCOME MEASURE

Regression of lesions after combination therapy.

RESULTS

Four of 5 patients had marked regression of the hemangioma by 40% to 60% with subsequent reduction in proptosis, corneal exposure, and obstruction of the visual axis. None of the 4 patients developed amblyopia. Side effects included mild neutropenia and uncomplicated infections. There was no neurologic toxicity after a median follow-up of 10 months. One patient failed to respond to treatment and required further treatment with intralesional steroid injections.

CONCLUSIONS

Combination of low-dose cyclophosphamide with IFNalpha2a for a short period of time induced early and lasting regression of orbital juvenile capillary hemangiomas with minimal side effects. This regimen may be a suitable alternative that avoids the toxicity of long-term administration of interferon only. However, the experience reported here does not show if cyclophosphamide alone may be sufficient and allow complete avoidance of interferon and its potential serious side effects, and longer follow-up is needed to determine if cyclophosphamide causes any long-term harm.

Clinical and imaging characteristics of orbital leukemic tumors

PURPOSE

To characterize the clinical and imaging features of orbital leukemic tumors in 27 patients seen and treated at St. Jude Children's Research Hospital.

METHODS

A retrospective review was performed on the clinical and imaging records of 27 consecutive patients with a diagnosis of orbital leukemic tumors. The following data were extracted from the patients' records: age at diagnosis of orbital leukemic tumors, sex, race, national origin, type of leukemia, temporal relationship of orbital disease to diagnosis of leukemia, survival from diagnosis of orbital leukemic tumor, laterality of the orbital disease, location of the mass within the orbit, imaging features of the mass, chemotherapeutic protocol, treatment with bone marrow transplant, and orbital radiation.

RESULTS

The median age at diagnosis of orbital leukemic tumor was 8 years (range, 1-18 years). Nineteen of the 27 patients were male, and 21 patients were born and lived in the United States. Twenty-one patients had acute myeloid leukemia, five had acute lymphoblastic leukemia, and one had chronic myelogenous leukemia. In 85% of patients (n = 23), the diagnosis of leukemia was based on the bone marrow examination findings. Orbital imaging revealed homogenous masses that molded to one or more orbital walls without bony destruction. Nine patients had bilateral orbital involvement. All patients received multiagent systemic chemotherapy, and 14 underwent bone marrow transplantation. Five patients received external beam radiation for the treatment of orbital disease. Fifteen (55.6%) of the 27 patients were alive at the time of the study. The median survival for all patients was 4.75 years (range, 0.1-24 years) after the diagnosis of orbital disease.

CONCLUSIONS

Orbital leukemic tumors occur most commonly in the first decade of life, in association with acute myeloid leukemia. They appear as homogenous masses along the orbital walls. Although the overall survival rate for patients with leukemia has improved over the past 3 decades, the mortality of patients who develop orbital leukemic tumors remains high.

Orbital and eyelid manifestations of xanthogranulomatous diseases

Erdheim-Chester disease, adult periocular xanthogranuloma, juvenile xanthogranuloma, and necrobiotic xanthogranuloma are presumed to be separate disease entities, but they are often confused clinically because of their similar presentations and histopathology. To further describe the xanthogranulomatous diseases and to identify possible pitfalls in their diagnoses, we retrospectively reviewed charts from 1998 to 2001 for all patients with biopsy-proven xanthogranulomatous process of the eyelid and/or orbit. We found 2 patients diagnosed with adult periocular xanthogranuloma and 1 with Erdheim-Chester disease, each case initially misdiagnosed. Careful review of the clinical manifestations, histopathological review of all previous biopsy specimens, and repeat biopsy aided in the correct diagnosis and management of disease in these 3 patients.

Socioeconomic impact of modern multidisciplinary management of retinoblastoma

OBJECTIVE

Our objective for this study was to examine the impact of the modern management of intraocular retinoblastoma on the patient and the family.

METHODS

This study comprises a retrospective, noncomparative case series of 25 consecutive patients with multifocal, intraocular retinoblastoma that was treated with primary systemic chemotherapy. Medical charts were reviewed, and the following data were extracted: patients' age and gender, laterality of disease, and Reese-Ellsworth classification of each eye as well as the number of central venous lines placed, cycles of chemotherapy received, outpatient appointments, examinations under anesthesia, focal therapies administered, computed tomography/MRI, radiation treatments, anesthetic procedures administered, and miles traveled.

RESULTS

Twenty patients with bilateral and 5 with unilateral intraocular retinoblastoma (median age: 9.3 months) had 895 outpatient appointments and underwent 698 examinations under anesthesia with 230 focal therapies, 347 days of radiotherapy, 226 computed tomography scans/MRIs, and 38 central venous line placements. A total of 1272 anesthetic procedures (median: 50) were performed with no major complication. In all, patients traveled 822312 miles (median: 22214 miles) to receive their care. The median follow-up was 82 months.

CONCLUSIONS

Successful retinoblastoma management requires close surveillance, aggressive consolidation, and numerous anesthetic procedures, all of which the patients and the families must endure. There is a significant impact on the patient, the family, and hospital resources.

Indications for Orbital Exenteration in Mucormycosis

PURPOSE

To determine whether evidence-based standards exist regarding the indications for orbital exenteration in patients with orbital mucormycosis.

METHODS

A literature review was performed of 113 articles (1943 to 2004). Factors possibly related to patient survival were analyzed. Additionally, a survey was sent to all ASOPRS Fellowship Preceptors to ascertain the frequency, outcome, treatment modalities, and indications for exenteration by these practicing physicians.

RESULTS

For published cases, parameter estimates (PE <or= 1.00) indicated that patients with mucormycosis with age >46 years, frontal sinus involvement, and fever were less likely to survive compared with patients without these conditions. Patients treated with amphotericin B (OR, 4.476) and those with diabetes (OR, 4.987) were more likely to survive compared with patients without these conditions. Exenterated patients with fever were more likely to survive compared with nonexenterated patients with fever (P=0.0468). Thirty-four ASOPRS Fellowship Preceptors received surveys; 26 (76%) completed the survey. Responses to specific survey questions showed a varied experience and indication for exenteration throughout the country.

CONCLUSIONS

: Our study underscores the lack of adequate data regarding the evaluation of treatment of orbital mucormycosis. No standard of care currently exists to guide physicians on when exenteration may benefit a mucormycosis patient. Further study is needed to determine which variables indicate the extent of disease and which variables or analytic scheme might predict the progression of orbital mucormycosis with or without exenteration.

Effect on ocular survival of adding early intensive focal treatments to a two-drug chemotherapy regimen in patients with retinoblastoma

PURPOSE

To evaluate vincristine and carboplatin with intensive focal treatments in the management of intraocular retinoblastoma.

DESIGN

Noncomparative, retrospective interventional case series.

METHODS

SETTING

Institutional.

PATIENT POPULATION

Sixteen patients (11 bilateral, 5 unilateral) with intraocular retinoblastoma. Interventional procedures: Patients were treated with eight courses of vincristine and carboplatin. Intensive focal treatments were administered after two courses of chemotherapy.

MAIN OUTCOME MEASURES

Avoidance of external beam radiotherapy (EBRT) and eye survival.

RESULTS

Twenty eyes (74.1%) were classified as Reese-Ellsworth Group V. All eyes responded to chemotherapy. With a median follow-up of 23 months (range 10 to 33 months) and a median of 5.5 focal treatments per eye (range 0 to 19 treatments), ocular survival was 81%. Eight eyes (30%) in five patients received EBRT.

CONCLUSIONS

Vincristine and carboplatin combined with intensive focal treatments is an effective regimen for patients with intraocular retinoblastoma. This treatment regimen has outcomes comparable to those of more toxic regimens and merits further evaluation.

Bloody Tears of Unknown Cause

PURPOSE

To report 4 cases of recurrent unilateral bloody tears.

METHODS

Retrospective case series.

RESULTS

One boy and 3 girls, ranging in age from 6 to 14 years, reported spontaneous bloody tearing. Workup included probing and irrigation of the nasolacrimal system, blood and coagulation profiles, blood typing, serum hormone levels, conjunctival biopsy, and imaging. All findings were normal and failed to suggest a cause in any of the cases. In all patients, bloody tearing eventually resolved without further sequela. No recurrence has been reported over a follow-up period of 9 months to 11 years.

CONCLUSIONS

Bloody tearing is an unusual clinical entity that concerns patients and can perplex physicians. A thorough examination and proper workup are necessary to rule out serious conditions but may fail to determine a cause. These idiopathic cases typically resolve without treatment.

Infliximab in the Treatment of Recalcitrant Idiopathic Orbital Inflammation

A 15-year-old boy had bilateral idiopathic orbital inflammation refractory to treatment with corticosteroids. He was not only unresponsive to subsequent therapy with methotrexate but also had elevation of serum liver enzymes. In an attempt to minimize further side effects of corticosteroids and to avoid external beam radiation in an adolescent, we began treatment with infliximab, an anti-tumor necrosis-alpha antibody. His symptoms resolved and his disease has not recurred. Use of infliximab may be useful in the treatment of recalcitrant idiopathic orbital pseudotumor.

Episcleral plaque brachytherapy for retinoblastoma

BACKGROUND

The purpose of this study was to report our experience using episcleral plaque brachytherapy (EPBRT) to treat retinoblastoma and to demonstrate its applicability in multimodality treatment.

PROCEDURE

We treated 26 tumors in 25 eyes from a group of 21 children with unilateral (n = 4) or bilateral (n = 17) retinoblastoma. The group comprised 8 girls and 13 boys; the median age was 25 months (range: 2-64 months) at the time of EPBRT. Iodine-125 ((125)I) was used for all applications. The median dose was 44 Gy (range: 35-47.6 Gy). EPBRT was administered primarily at the time of relapse after primary chemotherapy or radiation therapy.

RESULTS

For eyes treated with EPBRT, the eye preservation rate was 15/25 with a median follow-up of 47 months (range: 2-198 months); the lesion control rate was 25/26 with a median follow-up of 13 months (range: 1-140 months). The median time to additional whole-eye treatment after EPBRT was 12 months (range: 2-105 months).

CONCLUSIONS

Similar to previously reported series, EPBRT shows a high rate of successful tumor control as a primary treatment for retinoblastoma, as well as a secondary therapy at the time of relapse. EPBRT also allows for a clinically significant delay in the time to additional measures for the affected eye. Therefore, EPBRT should be considered as a form of local ophthalmic therapy that avoids or delays the use of external-beam radiotherapy, especially for patients primarily treated with chemotherapy who might require consolidation therapy.

Retained intraorbital metallic foreign bodies

PURPOSE

To document the biological tolerance of retained metallic orbital foreign bodies managed with conservative treatment.

METHODS

A retrospective chart review of 43 patients treated between 1987 and 1993 with retained intraorbital metallic foreign bodies was performed. Age, sex, injury, imaging studies obtained, location of the foreign body, initial and final visual acuity, length of follow-up, treatment, and related adverse reactions and/or complications were recorded.

RESULTS

Fifty cases involving 34 male and 9 female patients ranging in age from 2 through 63 years (median, 25 years) were included. Seventeen cases were the result of gunshot wounds, 17 were from BB gun injuries, and 16 cases were from shotgun injuries. Forty-two patients had CT scans to assess the injury and one patient had plain radiographs. In 37 cases, the metallic foreign bodies were located posterior to the globe. There were 19 ocular penetrating injuries, 11 ocular contusion injuries (sclopetaria, commotio retinae, vitreous hemorrhages), and 20 injuries with no ocular involvement. Initial visual acuity ranged from 20/20 to no light perception, as did final visual acuity. The metallic foreign bodies were retained from 6 months to 68 years (median, 2 years). There were 19 ocular penetrating injuries, including 12 enucleations and 7 primary repairs. When contusion injuries were sustained, treatment consisted of vitrectomy for the removal of persistent hemorrhages (3 cases), exploration of the globe (1 case), and nonsurgical treatment (7 cases). Among the 20 cases with no ocular involvement, only 2 patients had secondary complications that required surgical intervention: One had mechanical strabismus, the other a sterile abscess. Visual acuity remained stable or improved in all cases. There were no late complications from the retained foreign bodies in 36 (95%) of 38 cases when the eye remained intact.

CONCLUSIONS

Retained intraorbital metallic foreign bodies are well-tolerated and typically have minimal adverse visual prognosis. They should be managed conservatively in the absence of specific indications for removal.

Manifestations of Fungal Cellulitis of the Orbit in Children with Neutropenia and Fever

PURPOSE

To delineate clinical manifestations of fungal orbital cellulitis in immunocompromized patients.

METHODS

The charts of 7 pediatric patients with fungal orbital cellulitis treated at a tertiary children's cancer hospital were reviewed retrospectively for histologically confirmed fungal sinusitis with associated orbital cellulitis. Patients underwent CT and/or MRI of the orbits, sinuses, and brain; surgery; and therapy with antifungal medications. Main outcome measures were presenting signs and patient survival.

RESULTS

Twenty-four patients with fungal sinusitis were identified, 7 of whom (4 months to 15 years of age) had documented orbital fungal cellulitis. All 7 patients presented with neutropenia and fever. Presenting symptoms included edema of the upper eyelid (n=4), headache (n=1), and facial pain (n=1). One patient was asymptomatic. Although antifungal therapy was initiated within 24 hours of presentation, disease progressed, and 5 patients eventually died of their infections.

CONCLUSIONS

Because fungal orbital cellulitis can be fatal even if detected early in patients who are immunocompromised, ophthalmologists and otolaryngologists should be alert to the disease's subtle clinical manifestations.

Primary pelvic telangiectatic osteosarcoma metastatic to both orbits

We report a case of a 23-year-old man with primary pelvic telangiectatic osteosarcoma metastatic to both orbits. The patient had proptosis with optic neuropathies and intermittent third nerve palsies. His disease was unresponsive to chemotherapy or radiotherapy, and extensive craniofacial involvement precluded surgical resection. The patient died of his disease. Telangiectatic osteosarcoma, a rare variant of osteosarcoma that is distinguished by blood-filled cystic spaces, may metastasize to the orbit and skull base. Because telangiectatic osteosarcoma may radiographically resemble other benign and malignant lesions, biopsy is essential for accurate diagnosis that will ultimately dictate clinical therapy. However, patients with this disease have a poor prognosis.

Ophthalmic Injuries in Children Involved in All-Terrain Vehicle Crashes

PURPOSE

To describe the spectrum of ophthalmic injuries in children involved in all-terrain vehicle (ATV) crashes.

METHODS

We retrospectively reviewed the medical records of a level 1 children's trauma center to identify cases with ICD-9 codes pertaining to crashes involving ATVs and cross-referenced for ophthalmic trauma. From these cases, we documented the nature of the crash, patient's age, ophthalmic injuries received, and length of hospitalization.

RESULTS

Twenty children, 5 to 16 years of age (mean, 11.1 years), involved in ATV crashes were admitted between June 1997 and April 2002. One was riding with an adult and 3 with other children; 16 were operating the vehicles alone at the time of their crashes. None was wearing a helmet, and all had head trauma. Nine patients had ophthalmic injuries, including lacerations of the eyelid (n = 5), orbital fractures (n = 9), and traumatic optic neuropathies (n = 2). The latter two had final visual acuities of count fingers and no light perception. The average length of hospitalization was 6.6 days.

CONCLUSIONS

Ophthalmic trauma is a frequent complication of ATV crashes involving children. Injuries may range from minor lacerations to complex orbital fractures; visual loss may be severe. We believe that the age of the vehicles' operators and their failure to wear protective helmets contribute to the severity of injuries.

Primary perineal alveolar rhabdomyosarcoma metastatic to an extraocular muscle

A 17-year-old boy diagnosed with an alveolar rhabdomyosarcoma involving the perineum and with extensive lymphadenopathy was treated with chemotherapy yet developed metastases to the head and neck 6 months into therapy. Ten months after initial diagnosis, while receiving salvage chemotherapy and radiotherapy, he returned with pain on movement of his left eye, proptosis, and ptosis of the left upper eyelid. Computed tomography (CT) revealed a mass within the left lateral rectus muscle that biopsy confirmed to be metastatic alveolar rhabdomyosarcoma. Despite continued chemotherapy and radiotherapy, he ultimately died of the disease. Alveolar rhabdomyosarcoma from distant sites rarely metastasizes to the extraocular muscles. However, our case shows that alveolar rhabdomyosarcoma may metastasize to the orbit and involve a single muscle.

Orbital inflammatory syndromes with systemic involvement may mimic metastatic disease

Physical examination of a 9-year-old girl with a 2-month history of swelling of the left orbit demonstrated an orbital mass, blepharoptosis, and proptosis. Computed tomography revealed a 2 x 3-cm mass in the superior left orbit that expanded orbital dimensions. Radiography showed abnormalities in the parietal and frontal bones and distal right tibia. Magnetic resonance imaging demonstrated an 8.5-cm abnormality of the marrow space of the right mid-tibia. Bone marrow biopsy was unremarkable. Orbital and tibial biopsies showed a nonspecific chronic inflammation. Idiopathic inflammation that involves the orbit (orbital pseudotumor) and that has systemic manifestations may mimic more serious conditions, such as metastases from rhabdomyosarcoma or Ewing sarcoma, chronic recurrent multifocal osteomyelitis (CRMO), and SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis). Accurate diagnosis requires careful clinical and pathologic examinations.

Treatment of metastatic retinoblastoma

PURPOSE

The risk for death in patients with retinoblastoma is increased in those who present with metastatic disease, and the role of intensive chemotherapy and autologous hematopoietic stem cell rescue in these patients remains unclear.

DESIGN

Nonrandomized interventional case series.

PARTICIPANTS

Four consecutive patients with metastatic retinoblastoma.

METHODS

We treated four patients with retinoblastoma metastatic to the bone and bone marrow with intensive chemotherapy, consolidation with megatherapy, and autologous hematopoietic stem cell rescue. Chemotherapy included courses of carboplatin and etoposide alternating with cyclophosphamide, etoposide, and either carboplatin or cisplatin. Radiation therapy was delivered to areas of bone metastases.

MAIN OUTCOME MEASURES

Patient survival.

RESULTS

All patients completed and responded to the scheduled therapy; complete response of the bone marrow disease was documented after two courses of chemotherapy in all cases. Two patients are long-term survivors.

CONCLUSIONS

The treatment described has been successful in obtaining disease-free survival in patients with metastatic retinoblastoma.

Treatment of intraocular retinoblastoma with vincristine and carboplatin

PURPOSE

To evaluate the efficacy of chemoreduction using vincristine and carboplatin in preventing or delaying external-beam radiotherapy (EBRT) or enucleation in patients with intraocular retinoblastoma.

PATIENTS AND METHODS

Twenty-five patients (43 eyes) with newly diagnosed intraocular retinoblastoma received primary treatment with eight courses of vincristine and carboplatin. Focal treatments were delayed until documentation of disease progression. Outcome measures for each eye were length of time to disease progression, avoidance or delay of EBRT, and globe survival. Event-free survival was defined as the length of time to EBRT or enucleation.

RESULTS

Disease in all eyes responded to chemotherapy and progressed in only two patients before completion of the eight courses of therapy. Disease in all but four eyes progressed and required focal treatments. Event-free survival estimates at 2 years were 59.2% +/- 12.0% for Reese-Ellsworth group I, II, and III eyes and 26.3% +/- 9.2% for group IV and V eyes. Nineteen eyes (44.2%) required EBRT and 13 eyes (30.2%) were enucleated. The ocular salvage rate was 83.3% for Reese-Ellsworth group I to III eyes and 52.6% for group IV and V eyes. For those patients receiving EBRT, the median time from enrollment to EBRT was 9.5 months (median age at EBRT, 21 months).

CONCLUSION

In combination with appropriate early intensive focal treatments, chemoreduction with vincristine and carboplatin, without etoposide, may be an alternative treatment for patients with early-stage intraocular retinoblastoma, although additional studies are needed. Patients with advanced intraocular disease require more aggressive treatments.

Clinical and pathological features of intracranial chordoma with orbital involvement in a child

We examined a 44-month-old girl with proptosis of the left eye. Magnetic resonance imaging showed a dumbbell-shaped mass involving the cavernous sinus with orbital extension. Biopsy and immunohistochemistry showed the tumor to be a primitive chordoma. Intracranial chordoma should be considered in the differential diagnosis of children with orbital lesions. Immunohistochemistry is helpful in differentiating chordomas from other primitive round-cell or spindle-cell tumors.

Occult orbital neuroblastoma detected after administration of an antitumor vaccine

A 6-year-old girl with neuroblastoma developed swelling and erythema of her right upper eyelid following administration of an interleukin-2 and lymphotactin gene-modified allogeneic neuroblastoma cell vaccine. Computed tomography demonstrated a cystic lesion in the subperiosteal space. A biopsy of the mass showed necrotic neuroblastoma with minimal associated inflammation. To our knowledge, this case represents the first description of occult orbital metastases in a patient with neuroblastoma detected after administration of an antitumor vaccine.

Conjunctival mycosis masquerading as melanoma

PURPOSE

To report a patient with a melanotic lesion of the conjunctiva that mimicked melanoma but proved to be a fungal infection on biopsy.

DESIGN

Interventional case report.

METHODS

A 75-year-old white man was examined for a 3-month history of a deeply pigmented lesion of the conjunctiva at the limbus of the right eye that closely resembled conjunctival melanoma. The lesion was completely excised.

RESULTS

Histologic examination revealed fungal elements without evidence of tumor.

CONCLUSION

Although rare, fungi should be included in the differential diagnosis of pigmented lesions of the conjunctiva.