Local and Systemic Toxicity of Intravitreal Melphalan for Vitreous Seeding in Retinoblastoma: A Preclinical and Clinical Study

doi:10.1016/j.ophtha.2014.03.028

Ophthalmology

Volume 121, Issue 9, September 2014, Pages 1810-1817

Presented at: the International Congress of Ophthalmic Oncology Meeting, October 2013.

https://doi.org/10.1016/j.ophtha.2014.03.028 Get rights and content

Purpose

Intravitreal melphalan is emerging as an effective treatment for refractory vitreous seeds in retinoblastoma, but there is limited understanding regarding its toxicity. This study evaluates the retinal and systemic toxicity of intravitreal melphalan in retinoblastoma patients, with preclinical validation in a rabbit model.

Design

Clinical and preclinical, prospective, cohort study.

Participants

In the clinical study, 16 patient eyes received 107 intravitreal injections of 30 μg melphalan given weekly, a median of 6.5 times (range, 5–8). In the animal study, 12 New Zealand/Dutch Belt pigmented rabbits were given 3 weekly injections of 15 μg of intravitreal melphalan or vehicle to the right eye.

Methods

Electroretinogram (ERG) responses were recorded in both humans and rabbits. For the clinical study, ERG responses were recorded at baseline, immediately before each injection, and at each follow-up visit; 82 of these studies were deemed evaluable. Median follow-up time was 5.2 months (range, 1–11). Complete blood counts (CBCs) were obtained on the day of injection at 46 patient visits. In the animal study, ERG responses were obtained along with fluorescein angiography, CBCs, and melphalan plasma concentration. After humane killing, the histopathology of the eyes was evaluated.

Main Outcome Measures

For the clinical study, we measured peak-to-peak ERG amplitudes in response to 30-Hz photopic flicker stimulation with comparisons between ERG studies before and after intravitreal melphalan. For the animal study, we collected ERG parameters before and after intravitreal melphalan injections with histopathologic findings.

Results

By linear regression analysis, over the course of weekly intravitreal injections in retinoblastoma patients, for every additional injection, the ERG amplitude decreased by approximately 5.8 μV. The ERG remained stable once the treatment course was completed. In retinoblastoma patients, there were no grade 3 or 4 hematologic events. One week after the second injection in rabbits, the a- and b-wave amplitude declined significantly in the melphalan treated eyes compared with vehicle-treated eyes (P<0.05). Histopathology revealed severely atrophic retina.

Conclusions

Weekly injections of 30 μg of melphalan can result in a decreased ERG response, which is indicative of retinal toxicity. These findings are confirmed at an equivalent dose in rabbit eyes by ERG measurements and by histopathologic evidence of severe retinal damage. Systemic toxicity with intravitreal melphalan at these doses in humans or rabbits was not detected.

Section snippets

Methods

Melphalan (Alkeran; GlaxoSmithKline, Bretford, UK) was reconstituted with the commercial sterile diluent supplied by the manufacturer. Once reconstituted (50 mg of melphalan in 10 ml of diluent), serial dilution of melphalan with sterile saline was performed. In clinical studies, the final concentration was 417 μg/ml, and this was filtered through a 0.22-μ filter. Thus, 0.07 ml of the final solution of melphalan was injected to deliver 30 μg per eye. In animals, the final concentration was 150

Clinical Study

We included 107 injections in 16 eyes (all Reese-Ellsworth Group VB and International Classification D) in this study. The median follow-up was 5.2 months (range, 1–11 months), median age was 43 months (range, 13–213 months), median weight was 16 kg (range, 8–67 kg), and median number of weekly injections administered was 6.5 injections (range, 5–8 injections).

Discussion

Our knowledge of retinal toxicity associated with intravitreal melphalan is established from limited clinical reports and 2 preclinical animal models. Ghassemi et al¹¹ demonstrated that 50-μg injections in human eyes can result in vitreous and subretinal hemorrhage, hypotonia, and phthsis. Salt-and-pepper retinopathy occurred in 43% of human eyes in the cohort studied by Munier et al³, although it is unclear whether this was more predominant with the 20- or 30-μg dose. In rabbit eyes, Ueda et al

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Citation Excerpt :
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: Financial Disclosure(s):

: Supported by The Fund for Ophthalmic Knowledge (Cleveland, OH), The New York Community Trust, and Research to Prevent Blindness. The sponsor or funding organization had no role in the design or conduct of this research.

^∗: Both authors (Dr. Francis and Dr. Schaiquevich) contributed equally as first authors.

^‡: Both authors (Dr. Chantada and Dr. Abramson) contributed equally as last authors.

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Original articleLocal and Systemic Toxicity of Intravitreal Melphalan for Vitreous Seeding in Retinoblastoma: A Preclinical and Clinical Study

Purpose

Design

Participants

Methods

Main Outcome Measures

Results

Conclusions

Section snippets

Methods

Clinical Study

Discussion

Exp Eye Res

Eye-preservation treatment of retinoblastoma with vitreous seeding

Jpn J Clin Oncol

A phase I/II study of direct intraarterial (ophthalmic artery) chemotherapy with melphalan for intraocular retinoblastoma: initial results

Ophthalmology

Intravitreal chemotherapy for vitreous disease in retinoblastoma revisited: from prohibition to conditional indications

Br J Ophthalmol

Intravitreal melphalan for refractory or recurrent vitreous seeding from retinoblastoma

Arch Ophthalmol

Intravitreal injection of melphalan in the treatment of retinoblastoma with vitreous cavity seeding

Chin Med J (Engl)

Evaluating the risk of extraocular tumour spread following intravitreal injection therapy for retinoblastoma: a systematic review

Br J Ophthalmol

ERG monitoring of retinal function during systemic chemotherapy for retinoblastoma

Br J Ophthalmol

Original article
Local and Systemic Toxicity of Intravitreal Melphalan for Vitreous Seeding in Retinoblastoma: A Preclinical and Clinical Study