Retinoblastoma CSF metastasis cured by multimodality chemotherapy without radiation.
OBJECTIVE
Cerebrospinal fluid (CSF) metastasis is the most difficult type of retinoblastoma metastasis to cure, even with bone marrow transplant. Most metastatic retinoblastoma cells express P-glycoprotein causing multidrug resistance (MDR). P-glycoprotein-rich blood vessels form blood-brain and blood-eye barriers, inhibit drug entry into central nervous system (CNS) and eyes. High-dose craniospinal radiation is too morbid for treatment of young children. To cure CSF metastasis without radiation, we designed an intensive multimodality chemotherapy regimen.


METHODS
After left eye enucleation, a 4-month-old boy with bilateral International Intraocular Retinoblastoma Classification Group E eyes and CSF metastasis was treated with 7-cycle high-dose carboplatin and etoposide, standard-dose vincristine, and high-dose/short-infusion cyclosporine to inhibit P-glycoprotein. Intraventricular drugs, non-substrate of P-glycoprotein (cytarabine), or less susceptible to MDR (topotecan), contributed to treatment of the metastasis. On achieving complete response, he was consolidated with supralethal-dosage carboplatin, etoposide, and cyclophosphamide, and his bone marrow rescued with autologous cord blood stem cells.


RESULTS
Following 1-cycle systemic chemotherapy and 2-dose intraventricular chemotherapy, the CSF metastasis cleared. The right eye tumor regressed completely. The patient remains in remission 8.3 years after diagnosis and 7.8 years post-transplant.


CONCLUSIONS
Intensive multimodality chemotherapy can cure CSF metastasis in retinoblastoma without incurring extreme morbidity from craniospinal radiation.
Dimaras
Helen
H
Division of Hematology/Oncology, The Hospital for Sick Children, and The University of Toronto, Toronto, Ontario, Canada.
Héon
Elise
E
Budning
Andrew
A
Doyle
John J
JJ
Halliday
William
W
Gallie
Brenda L
BL
Chan
Helen S L
HS
D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D016190:Carboplatin / Q000008:administration & dosage; D016543:Central Nervous System Neoplasms / Q000134:cerebrospinal fluid / Q000556:secondary / Q000628:therapy*; D002555:Cerebrospinal Fluid; D003131:Combined Modality Therapy; D036101:Cord Blood Stem Cell Transplantation; D003520:Cyclophosphamide / Q000008:administration & dosage; D003561:Cytarabine / Q000008:administration & dosage; D005047:Etoposide / Q000008:administration & dosage; D015353:Eye Enucleation; D006801:Humans; D007223:Infant; D008297:Male; D011379:Prognosis; D019572:Retinal Neoplasms / Q000134:cerebrospinal fluid / Q000473:pathology / Q000628:therapy*; D012175:Retinoblastoma / Q000134:cerebrospinal fluid / Q000556:secondary / Q000628:therapy*; D014182:Transplantation, Autologous; D016896:Treatment Outcome; D014750:Vincristine / Q000008:administration & dosage
D003561:Cytarabine; D014750:Vincristine; D005047:Etoposide; D003520:Cyclophosphamide; D016190:Carboplatin