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Francis L Munier, Marie-Claire Gaillard, Aubin Balmer, Susan Houghton, Maja Beck Popovic; Intravitreal chemotherapy virtually eradicates indication to external beam irradiation for vitreous seeding in retinoblastoma. Invest. Ophthalmol. Vis. Sci. 2014;55(13):6018.
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Vitreous seeding is the worst prognostic factor for eye survival and still represents the most common indication for external beam irradiation and/or enucleation. Here we present the long term follow-up on a published series (Munier et al.Brit J Ophthalmol 2012) treated by intravitreal chemotherapy (IVC) and describe the results of a newly recruited cohort of patients presenting with active vitreous seeding.
Fifty nine consecutive heavily pretreated patients (63 eyes) eligible for IVC were reviewed, including the first series of 23 eyes with globe retention achieved in 20 eyes. The combined 63 eyes received a total 358 IVC (20 to 40 micrograms melphalan) given every 7 to 10 days. Ocular status was monitored under anesthesia with fundus photography, fluorescein angiography, and optic coherence tomography. Additional treatments, including chemohyperthermia, hyperthermia, photocoagulation, periocular topotecan, intra-arterial melphalan, and brachytherapy were applied as necessary to control the retinal tumors.
The follow-up of our initial cohort of 23 patients (20 conserved eyes) is marred by the loss of 2 children. One child had undergone enucleation but was disease-free until lost to follow-up in the referral country. The other child showed no ocular recurrence after IVC with survival of 30 months, but was recently diagnosed with uncurable pinealoblastoma. The follow-up for the remaining 19 conserved eyes is extended with mean tumor-free survival of 34.8 months (range 17-49) and no recurrence observed. In the second cohort complete vitreous response is achieved in 37 of the 40 eyes (92.5%, with 3 cases still ongoing), with no evidence of tumor spread and only infraclinical retinal toxicity. Mean follow-up is 12 months (range 1-30). Additional focal treatments were required to achieve complete inactivation of retinal and subretinal tumors in 88% of the eyes.
In conclusion, not only can IVC reverse the negative prognostic value of vitreous seeding, but has virtually eradicated the indication to external beam radiotherapy. However it should be emphasized that full tumor control is only rarely achieved by IVC alone without concomitant treatment of the retinal source of the seeding as well as all other active retinal tumors.
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