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Lavasidis G, Strongylis M, Tzamalis A, Tsinopoulos I, Ntzani EE. Safety of intravitreal chemotherapy in the management of retinoblastoma: A systematic review of the literature. Crit Rev Oncol Hematol 2024; 200:104423. [PMID: 38897313 DOI: 10.1016/j.critrevonc.2024.104423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 06/05/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024] Open
Abstract
Intravitreal chemotherapy is used as a salvage therapy for retinoblastoma with persistent or recurrent vitreous seeding after primary treatment. To assess the safety of this technique, we conducted a systematic review of all studies reporting ocular toxicity data. Forty-eight trials involving 2,751 eyes were included. The most common complications were cataract, retinal toxicity, and vitreous hemorrhage. However, severe and permanent adverse events were limited, while the risk of extraocular dissemination, a significant concern, was practically eliminated through preventive techniques. Globe salvage rates ranged from 29% to 100%. In conclusion, intravitreal chemotherapy seems to improve prognosis of eyes with advanced disease, with an acceptable safety profile. Nevertheless, most relevant studies are retrospective, and no randomized trials have been performed. Recognizing the challenges regarding the conduct of randomized studies for such a rare pediatric cancer, we believe that multicenter trials through international collaborations can significantly enhance the available information.
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Affiliation(s)
- Georgios Lavasidis
- Evidence-based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, 45110 Ioannina, Greece; Department of Ophthalmology, Elpis General Hospital of Athens, Dimitsanas 7, 11522 Athens, Greece; MSc Ocular Surgery, School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece.
| | - Mara Strongylis
- Department of Pediatrics, Evangelisches Krankenhaus Lippstadt, Wiedenbrücker Str. 33, 59555 Lippstadt, Germany.
| | - Argyrios Tzamalis
- MSc Ocular Surgery, School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece; 2nd Department of Ophthalmology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, 56403 Thessaloniki, Greece.
| | - Ioannis Tsinopoulos
- MSc Ocular Surgery, School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece; 2nd Department of Ophthalmology, School of Medicine, Aristotle University of Thessaloniki, Papageorgiou General Hospital, 56403 Thessaloniki, Greece.
| | - Evangelia E Ntzani
- Evidence-based Medicine Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, 45110 Ioannina, Greece; Center for Evidence Synthesis in Health, Brown University School of Public Health, 121 South Main St., Providence, RI 02912, USA; Department of Epidemiology, Brown University School of Public Health, 121 South Main St., Providence, RI 02912, USA.
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Schaiquevich P, Francis JH, Cancela MB, Carcaboso AM, Chantada GL, Abramson DH. Treatment of Retinoblastoma: What Is the Latest and What Is the Future. Front Oncol 2022; 12:822330. [PMID: 35433448 PMCID: PMC9010858 DOI: 10.3389/fonc.2022.822330] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/24/2022] [Indexed: 01/09/2023] Open
Abstract
The management of retinoblastoma, the most common intraocular malignancy in children, has changed drastically over the last decade. Landmark developments in local drug delivery, namely, safer techniques for intravitreal chemotherapy injection and ophthalmic artery chemosurgery, have resulted in eye globe salvages that were not previously attainable using systemic chemotherapy or external beam irradiation. Novel drugs, oncolytic viruses, and immunotherapy are promising approaches in the treatment of intraocular retinoblastoma. Importantly, emerging studies of the pattern of tumor dissemination and local drug delivery may provide the first steps toward new treatments for metastatic disease. Here, we review recent advances in retinoblastoma treatment, especially with regard to local drug delivery, that have enabled successful conservative management of intraocular retinoblastoma. We also review emerging data from preclinical and clinical studies on innovative approaches that promise to lead to further improvement in outcomes, namely, the mechanisms and potential uses of new and repurposed drugs and non-chemotherapy treatments, and discuss future directions for therapeutic development.
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Affiliation(s)
- Paula Schaiquevich
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina,National Scientific and Technological Research Council (CONICET), Buenos Aires, Argentina
| | - Jasmine H. Francis
- Ophthalmic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States,Department of Ophthalmology, Weill/Cornell Medical School, New York, NY, United States
| | - María Belén Cancela
- Unit of Innovative Treatments, Hospital de Pediatría JP Garrahan, Buenos Aires, Argentina,National Scientific and Technological Research Council (CONICET), Buenos Aires, Argentina
| | - Angel Montero Carcaboso
- Hemato-Oncology, Hospital Sant Joan de Déu, Barcelona, Spain,Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Guillermo L. Chantada
- National Scientific and Technological Research Council (CONICET), Buenos Aires, Argentina,Hemato-Oncology, Hospital Sant Joan de Déu, Barcelona, Spain,Institute for Translational Research, Universidad Austral, Buenos Aires, Argentina,Research Department, Fundacion Perez-Scremini, Montevideo, Uruguay
| | - David H. Abramson
- Ophthalmic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States,Department of Ophthalmology, Weill/Cornell Medical School, New York, NY, United States,*Correspondence: David H. Abramson,
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Bogan CM, Kaczmarek JV, Pierce JM, Chen SC, Boyd KL, Calcutt MW, Bridges TM, Lindsley CW, Nadelmann JB, Liao A, Hsieh T, Abramson DH, Francis JH, Friedman DL, Richmond A, Daniels AB. Evaluation of intravitreal topotecan dose levels, toxicity and efficacy for retinoblastoma vitreous seeds: a preclinical and clinical study. Br J Ophthalmol 2021; 106:288-296. [PMID: 33972235 PMCID: PMC8788260 DOI: 10.1136/bjophthalmol-2020-318529] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/22/2022]
Abstract
Background Current melphalan-based intravitreal regimens for retinoblastoma (RB) vitreous seeds cause retinal toxicity. We assessed the efficacy and toxicity of topotecan monotherapy compared with melphalan in our rabbit model and patient cohort. Methods Rabbit experiments: empiric pharmacokinetics were determined following topotecan injection. For topotecan (15 μg or 30 µg), melphalan (12.5 µg) or saline, toxicity was evaluated by serial electroretinography (ERG) and histopathology, and efficacy against vitreous seed xenografts was measured by tumour cell reduction and apoptosis induction. Patients: retrospective cohort study of 235 patients receiving 990 intravitreal injections of topotecan or melphalan. Results Intravitreal topotecan 30 µg (equals 60 µg in humans) achieved the IC90 across the rabbit vitreous. Three weekly topotecan injections (either 15 µg or 30 µg) caused no retinal toxicity in rabbits, whereas melphalan 12.5 µg (equals 25 µg in humans) reduced ERG amplitudes 42%–79%. Intravitreal topotecan 15 µg was equally effective to melphalan to treat WERI-Rb1 cell xenografts in rabbits (96% reduction for topotecan vs saline (p=0.004), 88% reduction for melphalan vs saline (p=0.004), topotecan vs melphalan, p=0.15). In our clinical study, patients received 881 monotherapy injections (48 topotecan, 833 melphalan). Patients receiving 20 µg or 30 µg topotecan demonstrated no significant ERG reductions; melphalan caused ERG reductions of 7.6 μV for every injection of 25 µg (p=0.03) or 30 µg (p<0.001). Most patients treated with intravitreal topotecan also received intravitreal melphalan at some point during their treatment course. Among those eyes treated exclusively with topotecan monotherapy, all eyes were salvaged. Conclusions Taken together, these experiments suggest that intravitreal topotecan monotherapy for the treatment of RB vitreous seeds is non-toxic and effective.
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Affiliation(s)
- Carley M Bogan
- Ophthalmology & Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jessica V Kaczmarek
- Ophthalmology & Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Janene M Pierce
- Ophthalmology & Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sheau-Chiann Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelli L Boyd
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Thomas M Bridges
- Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee, USA
| | - Craig W Lindsley
- Center for Neuroscience Drug Discovery, Vanderbilt University, Nashville, Tennessee, USA
| | | | - Albert Liao
- Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Terry Hsieh
- Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - David H Abramson
- Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jasmine H Francis
- Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Debra L Friedman
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ann Richmond
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Pharmacology, Vanderbilt University, Nashville, Tennessee, USA.,VA Tennessee Valley Healthcare System Nashville Campus, Nashville, Tennessee, USA.,Program in Cancer Biology, Vanderbilt University, Nashville, Tennessee, USA
| | - Anthony B Daniels
- Ophthalmology & Visual Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA .,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Program in Cancer Biology, Vanderbilt University, Nashville, Tennessee, USA.,Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Daniels AB, Pierce JM, Chen SC. Complete preclinical platform for intravitreal chemotherapy drug discovery for retinoblastoma: Assessment of pharmacokinetics, toxicity and efficacy using a rabbit model. MethodsX 2021; 8:101358. [PMID: 34430259 PMCID: PMC8374393 DOI: 10.1016/j.mex.2021.101358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/12/2021] [Indexed: 02/07/2023] Open
Abstract
Current melphalan-based intravitreal chemotherapy regimens for retinoblastoma vitreous seeds are effective, but cause significant ocular toxicity. We describe protocols for each step of a drug discovery pipeline for preclinical development of novel drugs to maximize efficacy and minimize toxicity. These protocols include: 1) determination of vitreous pharmacokinetics in vivo, 2) in vitro assessment of drug cytotoxicity against retinoblastoma based on empiric pharmacokinetics, 3) back-calculation of minimum injection dose to achieve therapeutic concentrations, 4) in vivo determination of maximum-tolerable intravitreal dose, using a multimodal, structural and functional toxicity-assessment platform, and 5) in vivo determination of drug efficacy using a rabbit orthotopic xenograft model of retinoblastoma vitreous seeds. We likewise describe our methodology for direct quantitation of vitreous seeds, and the statistical methodology for assessment of toxicity and efficacy in evaluating novel drugs, as well as for comparisons between drugs.•Multi-step pipeline for intravitreal chemotherapy drug discovery for retinoblastoma, using novel rabbit models.•Detailed protocols for determination of vitreous pharmacokinetics, calculation of optimal dose to inject to achieve therapeutic vitreous levels, determination of maximum tolerable dose using a novel complete toxicity-assessment platform, and in vivo efficacy against retinoblastoma using methodology to directly quantify vitreous tumor burden.•Associated statistical methodology is also presented.
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Affiliation(s)
- Anthony B Daniels
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States.,Program in Cancer Biology, Vanderbilt University, Nashville, TN, United States.,Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Janene M Pierce
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Sheau-Chiann Chen
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, United States.,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
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Bogan CM, Pierce JM, Doss SD, Tao YK, Chen SC, Boyd KL, Liao A, Hsieh T, Abramson DH, Francis JH, Friedman DL, Richmond A, Daniels AB. Intravitreal melphalan hydrochloride vs propylene glycol-free melphalan for retinoblastoma vitreous seeds: Efficacy, toxicity and stability in rabbits models and patients. Exp Eye Res 2021; 204:108439. [PMID: 33444583 PMCID: PMC8117559 DOI: 10.1016/j.exer.2021.108439] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/15/2020] [Accepted: 01/05/2021] [Indexed: 11/22/2022]
Abstract
The use of intravitreal chemotherapy has revolutionized the treatment of advanced intraocular retinoblastoma, as intravitreal melphalan has enabled difficult-to-treat vitreous tumor seeds to be controlled, leading to many more eyes being saved. However, melphalan hydrochloride (MH) degrades rapidly in solution, increasing logistical complexity with respect to time between medication preparation and administration for intravitreal administration under anesthesia for retinoblastoma. A new propylene glycol-free melphalan (PGFM) formulation has greater stability and could therefore improve access and adoption of intravitreal chemotherapy, allowing more children to retain their eye(s). We compared the efficacy and toxicity of both formulations, using our rabbit xenograft model and clinical patient experience. Three weekly 12.5 μg intravitreal injections of MH or PGFM (right eye), and saline (left eye), were administered to immunosuppressed rabbits harboring human WERI-Rb1 vitreous seed xenografts. Residual live cells were quantified directly, and viability determined by TUNEL staining. Vitreous seeds were reduced 91% by PGFM (p = 0.009), and 88% by MH (p = 0.004; PGFM vs. MH: p = 0.68). All residual cells were TUNEL-positive (non-viable). In separate experiments to assess toxicity, three weekly 12.5 μg injections of MH, PGFM, or saline were administered to non-tumor-bearing rabbits. Serial electroretinography, optical coherence tomography (OCT) and OCT-angiography were performed. PGFM and MH both caused equivalent reductions in electroretinography amplitudes, and loss of retinal microvasculature on OCT-angiography. The pattern of retinal degeneration observed on histopathology suggested that segmental retinal toxicity associated with all melphalan formulations was due to a vitreous concentration gradient-effect. Efficacy and toxicity were assessed for PGFM given immediately (within 1 h of reconstitution) vs. 4 h after reconstitution. Immediate- and delayed-administration of PGFM showed equivalent efficacy and toxicity. In addition, we evaluated efficacy and toxicity in patients (205 eyes) with retinoblastoma vitreous seeds, who were treated with a total of 833 intravitreal injections of either MH or PGFM as standard of care. Of these, we analyzed 118 MH and 131 PGFM monotherapy injections in whom serial ERG measurements were available to model retinal toxicity. Both MH and PGFM caused reductions in electroretinography amplitudes, but with no statistical difference between formulations. Comparing those patient eyes treated exclusively with PGFM versus those treated exclusively with MH, efficacy for tumor control and globe salvage was equivalent (PGFM vs. MH: 96.2% vs. 93.8%, p = 0.56), but PGFM-treated eyes received fewer injections than MH-treated eyes (average 3.2 ± 1.9 vs. 6.4 ± 2.1 injections, p < 0.0001). Taken together, these rabbit experiments and our clinical experience in retinoblastoma patients demonstrate that MH and PGFM have equivalent efficacy and toxicity. PGFM was more stable, with no decreased efficacy or increased toxicity even 4 h after reconstitution. We therefore now use PGFM over traditional MH for our patients for intravitreal treatment of retinoblastoma.
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Affiliation(s)
- Carley M Bogan
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Janene M Pierce
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie D Doss
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yuankai K Tao
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA
| | - Sheau-Chiann Chen
- Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelli L Boyd
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Albert Liao
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Terry Hsieh
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Debra L Friedman
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ann Richmond
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA; Tennessee Valley Healthcare System, Department of Veterans Affairs, Nashville, TN, USA; Department of Pharmacology, Vanderbilt University, Nashville, TN, USA; Program in Cancer Biology, Vanderbilt University, Nashville, TN, USA
| | - Anthony B Daniels
- Division of Ocular Oncology and Pathology, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA; Program in Cancer Biology, Vanderbilt University, Nashville, TN, USA; Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, USA.
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