Treatment of retinoblastoma

Visual outcomes in children with bilateral retinoblastoma

BACKGROUND

Retinoblastoma is the most common primary intraocular tumor of childhood. Although studies have explored trends in retinoblastoma management and prognosis, few have addressed visual outcome.

METHODS

A retrospective chart review was performed on children in whom bilateral retinoblastoma was diagnosed at New York Hospital-Cornell Medical College. A total of 74 children were included in the study. All children underwent radiation to the eyes that were studied. Fundus drawings done at the time of diagnosis were evaluated to determine the location of tumors on presentation and the Reese-Ellsworth classification. Visual outcome was classified into 3 groups: group 1 represented visual acuity of 20/20 to 20/40; group 2, 20/50 to 20/400, and group 3, <20/400.

RESULTS

A total of 74 children were studied. Forty-six (62%) underwent enucleation of 1 eye. The visual acuity of the remaining 102 eyes was divided into groups 1, 2, and 3. Fifty-eight percent of these eyes were in group 1, 31% in group 2, and 9% in group 3. Two percent underwent subsequent enucleation after treatment. The tumors were analyzed on the basis of Reese-Ellsworth classification, location, size, and distance from the macula. Excluding Reese-Ellsworth group VB, there was no correlation between Reese-Ellsworth classification and final visual outcome. Tumors involving the macula were in 7 (78%) of 9 eyes with poor visual outcome (group 3), and 16 (33%) of 48 eyes with excellent vision (group 1) had macular tumors. Paradoxically, 2 (22%) of 9 eyes in group 3 did not have tumors involving the macula.

CONCLUSIONS

Children with retinoblastoma now have an excellent prognosis for life. Although correlated with tumor location, visual outcome is not always easily predicted on the basis of the initial presentation. Final acuity is excellent in most cases but may be influenced by multiple factors that must be considered when caring for these children and families.

Radiation therapy for retinoblastoma: a retrospective review of 120 patients

PURPOSE

To characterize the patient population and treatment outcomes in patients with Retinoblastoma (RB) referred for External Beam Orbital Radiotherapy (EBORT) to King Faisal Specialist Hospital & Research Centre (KFSH&RC), Riyadh, Saudi Arabia from 1976 to 1993.

METHODS AND MATERIALS

A retrospective study of 120 patients with RB affecting a total of 192 eyes. Patients were divided into three groups. Group A are 60 patients (64 eyes) treated with EBORT to the intact eye to preserve vision. Reese-Ellsworth (RE) Staging was: 1: 12%; 2: 10%; 3: 12%; 4: 23%; and 5: 43%. Twenty-eight patients (47%) also received Vincristine, Adriamycin, and Cyclophosphamide chemotherapy (C/T). Mean follow-up, per patient, was 48.5 months. Standard treatment until 1992 was 45 Gy in 12 fractions of 3.75 Gy, three times weekly over 18 days. Assuming the alpha/beta ratio for early effects and tumor control at 10, Tk = 21 days, Tpot = 5 days, then the Biological Equivalent Dose (BED) was 62 Gy10 for early effects, and 101 Gy3 for late effects. Group B are 28 patients (28 eyes) treated for curative intent with EBORT to the orbit for locally advanced disease, usually after enucleation (24 eyes). Nineteen patients (83%) also had C/T. Mean follow-up was 22.6 months. Group C are 37 patients with advanced disease treated with radiotherapy for palliation. Seventeen (46%) also received C/T. Mean follow-up was 11.7 months.

RESULTS

Group A-following EBORT useful vision was retained in RE Stage 1 to 5: 7 of 7, 6 of 6, 4 of 8, 10 of 15, and 7 of 28 eyes, respectively. There was no significant difference between patients who received adjuvant chemotherapy and those who did not. Complications included cataract (27%), retinopathy (25%), vitreous hemorrhage (19%), and orbital deformities (11%). In Group B the local control rate was 71%. In Group C, 10 (27%) of the 37 patients were alive at last contact, and 27 (73%) were either terminal or dead of disease. None of Group A or B patients had positive CSF cytology, bone scan, or bone marrow examination. In Group C 19% had positive CSF cytology, and bone marrow, and 14% had a positive bone scan.

CONCLUSIONS

1) EBORT preserved useful vision in a significant proportion of patients even in eyes with advanced RE Stage RB, but longer follow-up is likely to reveal an even higher complication rate with this regime. 2) High dose per fraction probably contributed to the increased complications. 3) Chemotherapy did not demonstrate any effect on retaining vision in this study. 4) For disease that is confined to within the eye clinically and radiologically, invasive procedures for CSF cytology, bone marrow examination, and bone scan do not seem warranted. 5) The optimum technique, fractionation, and dosage for RB is still not well defined.

Plaque radiotherapy for residual or recurrent retinoblastoma in 91 cases

Plaque radiotherapy has been used successfully as primary treatment for selected solitary retinoblastomas. However, there is relatively little information on its role as a secondary treatment after other methods have failed to control the tumor. We have used solitary plaque radiotherapy to treat 91 children with residual or recurrent retinoblastoma after failure of one or more treatment modalities, which included external beam radiotherapy in 63 children, plaque radiotherapy in 9, cryotherapy in 26, and photocoagulation in 18, for a total of 116 treatments in the 91 children. Despite the fact that enucleation was considered to be the only remaining option in many of these children, tumor regression was achieved in 81 cases (89%) and recurrence developed in only 10 cases (11%) during a mean follow up lf 52 months. Treatment of the recurrence following plaque radiotherapy in these 10 cases included repeat plaque radiotherapy in 6 cases, enucleation in 3 cases, and external beam radiotherapy in 1 case. In view of the fact that enucleation was being considered as the only remaining option in many of these children, control of the tumor with plaque radiotherapy in 89% of the cases is very encouraging. Plaque radiotherapy should be considered as an important option for recurrent retinoblastoma after failure of other methods to achieve tumor control.

An experience of the use of radioactive plaques after failure of external beam radiation in the treatment of retinoblastoma

The authors have reviewed the results of radioactive plaques in recurrent retinoblastoma after external beam radiation in 34 eyes. They give their results on ocular conservation and on the visual outcome and compare these results with other series previously published. They think radioactive plaques are an alternative to enucleation in recurrent retinoblastoma after external beam.

Plaque radiotherapy in the management of retinoblastoma. Use as a primary and secondary treatment

BACKGROUND

Radioactive episcleral plaque brachytherapy is a treatment method for selected retinoblastomas. The authors have used this technique since 1976 as both a primary and a secondary treatment method after other methods failed to achieve tumor control.

METHODS

A review of the records of 400 consecutive children with retinoblastoma showed that solitary plaque radiotherapy was used as a method of management in 103 cases. The authors' overall experience was evaluated, and the results between primary and secondary plaque therapies were compared in these 103 cases.

RESULTS

Of the 103 tumors, the mean basal diameter was 7 mm, and the mean thickness was 4 mm. Overlying vitreous seeds were clinically apparent in 50 cases (48%). The mean proximity of the tumor margin to the optic disc margin was 6 mm and to the foveola was 6 mm. The mean follow-up period was 40 months. In 89 cases (86%), the tumor was controlled by one plaque application, whereas in 13 cases (13%), tumor recurrence after initial tumor shrinkage necessitated subsequent treatment. Final visual outcome was good in 63 cases (62%), poor in 30 (29%), enucleation in 9 (9%), and unknown in 1 case. The poor vision was due to foveal retinoblastoma (with or without amblyopia) in 25 cases (83%). Eight of the nine enucleated eyes were treated initially with external beam radiotherapy then later with plaque radiotherapy. In 31 cases (30%), plaque radiotherapy was used as a primary treatment to the tumor, while in 72 cases (70%), it was a secondary form of management after failure of other methods to control the tumor. Statistical analysis showed that tumors treated with plaque radiotherapy as a primary measure were more likely to be larger in in base (P = 0.01) and thickness (P = 0.01) than secondary treated tumors. The secondary treated retinoblastomas were more likely to have vitreous seeds (P = 0.02) than the primary treated tumors. The rate of tumor control and patient survival was similar between the two groups.

CONCLUSION

Plaque radiotherapy is very effective in treating selected retinoblastomas with a high rate of tumor control and patient survival. It can be used successfully as a primary or a secondary treatment for tumors that have not been adequately controlled by other therapeutic methods.

Enucleation technique for children with retinoblastoma

Based on personal experience with approximately 350 enucleations for retinoblastoma, the authors describe their current surgical technique for removal of the eye, opening the globe to harvest fresh tissue for research including DNA analysis, and placement of the new hydroxyapatite orbital implant. Enucleation should be performed as gently as possible. A hemostat is placed on the stump of the severed medial rectus muscle for traction purposes, and long, minimally curved scissors are used to cut the optic nerve near the orbital apex. Clamps and snares are not advised and cautery of the orbital tissue is avoided. A piece of optic nerve is first submitted separately for histopathologic study and the globe is opened with a specific technique to harvest fresh tumor tissue. A hydroxyapatite implant covered by sterilized sclera is placed in the anophthalmic socket to provide orbital volume and improved motility of the prosthesis.

Visual acuity after successful treatment of large macular retinoblastoma

Recent trends in the treatment of retinoblastoma have favored radiation therapy as opposed to enucleation. A major determining factor in selecting radiation therapy is the possibility of useful posttreatment visual function. While the treatment of nonmacular tumors seems reasonable, little information is available about the posttreatment visual outcome of large posterior pole tumors. We treated 17 patients (20 eyes) with group III-V retinoblastoma and large posterior pole tumors with external beam radiation. Visual acuity after treatment ranged from 5/200 to 20/50. Potential posttreatment visual function was difficult to predict using such pretreatment factors as age at diagnosis, funduscopic appearance, and the number, size, and location of the tumors. Surprising visual function was obtained in some patients with multiple large macular tumors. Follow up ranged from 1 to 8 years. No patient developed metastatic disease; however, four patients required subsequent cataract extraction. This study supports the consideration of radiation therapy as the primary treatment in eyes previously felt to have a poor visual outcome.

Decreasing frequency of enucleation in patients with retinoblastoma

We reviewed our 15-year experience with the management of 324 cases of retinoblastoma. There has been a definite trend away from enucleation in both unilateral and bilateral cases during recent years. In cases of unilateral retinoblastoma, the affected eye was salvaged in 4% of cases (two of 49) during the five-year interval from 1974 through 1978, in 14% of cases (seven of 50) from 1979 through 1983, and in 25% of cases (20 of 80) from 1984 through 1988. In cases of bilateral retinoblastoma, both affected eyes were salvaged in 4% of cases (one of 24) from 1974 through 1978, in 18% of cases (nine of 50) from 1979 through 1983, and in 25% of cases (18 of 71) from 1984 through 1988. Earlier diagnosis of retinoblastoma and refinements in conservative methods of management are believed to be the main reasons for this trend away from enucleation.

Episcleral plaque radiotherapy for retinoblastoma

The authors report their preliminary results of episcleral plaque radiotherapy (cobalt 60, iridium 192, ruthenium 106, and iodine 125 plaques) in 50 selected patients with retinoblastoma. There were 97 plaque applications to 51 affected eyes in these 50 patients. The plaque was used as primary treatment in 15 eyes and as secondary treatment after failure of external beam radiotherapy, photocoagulation, and/or cryotherapy in 36 eyes. Vitreous seeding of tumor cells was evident ophthalmoscopically in 49 of the 51 eyes, negating the possibility of ultimate success by further photocoagulation or cryotherapy. In 18 patients, the contralateral eye had been enucleated and the remaining eye was being considered for enucleation because all other treatment modalities had failed. In 2 of these 18 patients (11%), the remaining eye was salvaged with plaque radiotherapy and some vision was preserved. In 33 eyes with less advanced tumors, 31 had some degree of vitreous seeding by tumor cells. The eye has been retained in all 33 of these patients and useful vision preserved in most. On the basis of these preliminary observations, the authors conclude that plaque radiotherapy can be used successfully as a primary treatment for selected cases of unilateral or bilateral retinoblastoma or as a supplemental treatment after other treatment methods have failed. The current indications for plaque radiotherapy and its advantages over other therapeutic modalities are discussed.

Current approaches to the diagnosis and management of retinoblastoma

Retinoblastoma is the most common primary intraocular malignancy of childhood, occurring in about one out of 15,000 live births. A century ago, the mortality rate with this malignancy was nearly 100%; today, it is less than 10%. Furthermore, with recent advances in both diagnostic and therapeutic techniques, vision can often be preserved in one or both eyes. The approach to differential diagnosis utilized in the Wills Eye Hospital Ocular Oncology Service is outlined, and various diagnostic tests are described and illustrated. Procedures for examination under anesthesia are also detailed; it is emphasized that the physician should be prepared to institute appropriate treatment at the time of examination under anesthesia. Depending on the extent and nature of tumor involvement, treatment might consist of enucleation, external radiation, episcleral plaque irradiation, photocoagulation, cryotherapy, chemotherapy or a combination of these modalities. Indications, techniques and complications of each modality are discussed.

Stage-related combined modality treatment of retinoblastoma. Results of a prospective study

Forty-two consecutive patients with retinoblastoma were evaluated by a new staging system and combined modality therapy instituted according to stage. Nineteen patients had bilateral tumors and 23 had unilateral tumors. The staging system was effective in identifying subpopulations of patients and successfully predicted those at greater risk of recurrence or death. Thirty-nine of 42 patients survive (Median survival time, 42 months). Two of 4 children with tumor extension beyond the eye died while 37 of 38 children with tumor presumed confined to the eye survive. Toxicity of the chemotherapy was mild. Radiation therapy of intraocular tumor was associated with cataract formation but most children had satisfactory vision after extraction and the use of corrective lenses. Ophthalmologic findings did not always correlate with histologic extent of tumor and both should be used in planning and evaluating treatment. Recommendations are made on the role of chemotherapy and the need to reduce the morbidity of treatment.

Computed tomographic scanning in the management of retinoblastoma

We used the computed tomographic scanner in the assessment of ten cases of retinoblastoma in children. With each patient the stage of the disease before operation could be more accurately defined and therefore more definite treatment could be undertaken.

Laser applications in medicine and biology: a bibliography

This bibliography covers the period from 1963 through 1974; 916 references are classified under 23 subject headings. The references are arranged chronologically.

Radiation treatment of retinoblastoma

In a series of 45 children with retinoblastoma, from the period 1953-1973, comprising 27 bilateral cases, 32 eyes were treated by irradiation. The different techniques of radiation are reviewed. In the present series small tumours were irradiated by local application of Stallard discs or Rosengren balls, while advanced cases were treated by external radiation. The results are discussed, and it is emphasized that the major factor of importance for the success of the treatment is the size of the tumour. Small tumours are cured, large ones are not. Future efforts must be directed towards early diagnosis. The treatment should be centralized in order to secure sufficient experience for the ophthalmologist and radiotherapist, as evaluation of the post- radiation fundus findings may present difficulties.