Combined chemoreduction and adjuvant treatment for intraocular retinoblastoma.

OBJECTIVE: The purpose of the study is to investigate chemoreduction and adjuvant treatment (AT) for retinoblastoma and its effect on complete retinal tumor control, vitreous seed control, and subretinal seed control. DESIGN: The study design was a prospective, nonrandomized clinical trial. PARTICIPANTS: There were 130 intraocular retinoblastomas in 52 eyes of 32 consecutive patients observed for at least 1 year after initiation of treatment. INTERVENTION: Treatment with chemoreduction using vincristine, etoposide, and carboplatin (VEC) and adjuvant treatment (+ AT) (cryotherapy, laser photocoagulation, thermotherapy, chemothermotherapy, plaque radiation therapy, or external beam radiation therapy) were assessed. MAIN OUTCOME MEASURES: The effect of chemoreduction for 6 cycles (VEC x 6) versus fewer than 6 cycles (VEC x <6) on retinoblastoma control was analyzed. Furthermore, the impact of adjuvant treatment (+ AT) versus no adjuvant treatment (no AT) on retinoblastoma control was analyzed. RESULTS: Retinal tumors showed favorable initial regression with chemoreduction. Adjuvant treatment was applied to 93% of the retinal tumors after chemoreduction and only 2% recurred over the mean follow-up of 17 months (range 13-27 months). Vitreous seeds and subretinal seeds showed initial regression and often complete disappearance with chemoreduction. In those eyes with seeds before treatment, the addition of AT to VEC for 6 cycles decreased the vitreous seed recurrence from 75% to 0% (P = 0.04) and also decreased the subretinal seed recurrence from 67% to 0% (P = 0.003). More important, when considering that enucleation or external beam radiation therapy was the only other treatment option for these 52 eyes, the authors were successful in avoiding these methods in 42% of cases. Of the 36 eyes classified as Reese-Ellsworth group 5, there was 78% ocular salvage, and external beam radiation therapy was avoided in 25% of these eyes. There was a 100% ocular salvage in the group 5 eyes that received VEC for 6 cycles + AT to retinal tumors and seeds. CONCLUSIONS: Chemoreduction and AT to intraocular retinoblastoma and its seeds provides good retinal tumor control, even in eyes with advanced disease. Chemoreduction alone generally is not adequate to achieve complete tumor seed control. Cautious follow-up of affected patients is recommended because the risk for recurrent vitreous and subretinal seeds is substantial and proper treatment is critical for salvaging the eye.

Transpupillary thermotherapy in the management of choroidal melanoma.

BACKGROUND: Several methods of treatment have been used for choroidal melanoma. The purpose of this report is to evaluate the effectiveness of transpupillary thermotherapy using near-infrared radiation to treat choroidal melanoma. METHODS: A prospective study was conducted to evaluate the clinical features, treatment results, and complications of patients with choroidal melanoma who were treated with transpupillary thermotherapy delivered over one to four sessions and followed for at least a 6-month period. All treated tumors had either documentation of growth or ophthalmoscopic risk factors for future growth and/or metastasis. RESULTS: There were 17 patients with choroidal melanoma treated with transpupillary thermotherapy. The mean tumor size before treatment was 6.6 mm in base and 3.0 mm in thickness. The tumor margin was a mean of 2.3 mm from the optic disc and 2.7 mm from the foveola. Seven tumors (41%) touched the optic disc margin and three (18%) were under the fovea. The tumor responded to treatment in all patients, with a decrease in thickness and resolution of associated subretinal fluid. At a minimum of 6 months of follow-up, the mean tumor thickness was 1.7 mm, and the tumor site was a residual chorioretinal scar with partial visibility of the sclera in all patients. Despite the proximity to the optic disc and foveola, the final visual acuity was the same or improved in ten eyes (59%) and decreased in seven (41%). The improved vision was due to resolution of subfoveal fluid, whereas the decreased vision was primarily the result of treatment in the fovea with ultimate retinal vascular occlusion or preretinal traction. Although long-term follow-up is not yet available, there were no patients with tumor recurrence or tumor metastases. CONCLUSIONS: This preliminary study demonstrates that transpupillary the thermotherapy appears to be an effective treatment for selected small choroidal melanomas and may be a particularly useful modality for treating those tumors near the foveola and optic disc. Longer follow-up is necessary to assess for local recurrence and the impact of treatment on survival.