AnnLeahey, MD, Pediatric Oncologist, Children's Hospital of Philadelphia
AnnaMeadows, MD, Pediatric Oncologist, Children's Hospital of Philadelphia
Other Contributors:
February 05, 2018
Having read the article of secondary primary malignancies (SPM) in patients treated with ophthalmic artery chemosurgery (OAC) (1), we wish to update Dr. Habib’s report. A patient with unilateral Group D heritable retinoblastoma (RB) treated by their team with 5 OAC treatments in 2012 through 2013 developed acute myeloid leukemia (AML) on 4/26/2017 and died 3 months later.
Following an intraocular recurrence after OAC and subsequent enucleation the patient’s care was transferred to our institution. Despite adjuvant chemotherapy he developed widespread bone and marrow metastases 8 months after enucleation. He then underwent intensive chemotherapy and an autologous stem cell transplant. Twenty eight months later he developed AML with a fms-like tyrosine kinase 3 (FLT3) mutation. Melphalan administered during all OAC treatments and the drugs administered following that failure must be implicated in this outcome (2). By failing to eradicate retinoblastoma, metastatic disease ensued requiring further treatment and subsequently, AML.
The author’s report is profoundly misleading with regard to the risk of SPMs following OAC. Although the maximum period of follow-up is 12 years, the median is 2.5 years. Patients failing OAC required radiation therapy and are known to be 3 times more likely to develop additional cancers (3). We await that follow-up.
The goal of RB care is cure. This patient’s course illustrates the danger of failing to prevent metastatic disease with initial therapy. As Dr. Desjardins wrote in her recent review “ local administration [via OAC] cannot be used to treat micrometastases in advanced forms of the disease “ (4). Although metastatic RB can be treated if it develops (5), not all patients survive.
References:
1. Habib LA, Francis JH, Fabius A et al. Second primary malignancies in retinoblastoma patients treated with intra-arterial chemotherapy: the first 10 years. Br J Ophthalmol 2018; 102: 272-5.
2. Levine EG and Bloomfield CO. Leukemias and myelodysplastic syndromes secondary to drugs, radiation and environmental exposures. Semin Oncol 1982; 19: 471-84.
3. Kleinerman RA, Tucker MA, Tarone RE, et al. Risk of new cancers after radiotherapy in long-term survivors of retinoblastoma: an extended follow-up. J Clin Oncol 2005; 23: 2272-9.
4. Kassoux N, Lumbroso L, Levy-Gabriel C et al. Retinoblastoma: updates on current management. Asia-Pac J Ophthalmol 2017; 6: 290-5.
5. Dunkel IJ, Khakoo Y, Kernan NA et al. Intensive multi-modal therapy for patients with stage 4A metastatic retinoblastoma. Pediatr Blood Cancer 201; 55: 55-9.
Having read the article of secondary primary malignancies (SPM) in patients treated with ophthalmic artery chemosurgery (OAC) (1), we wish to update Dr. Habib’s report. A patient with unilateral Group D heritable retinoblastoma (RB) treated by their team with 5 OAC treatments in 2012 through 2013 developed acute myeloid leukemia (AML) on 4/26/2017 and died 3 months later.
Following an intraocular recurrence after OAC and subsequent enucleation the patient’s care was transferred to our institution. Despite adjuvant chemotherapy he developed widespread bone and marrow metastases 8 months after enucleation. He then underwent intensive chemotherapy and an autologous stem cell transplant. Twenty eight months later he developed AML with a fms-like tyrosine kinase 3 (FLT3) mutation. Melphalan administered during all OAC treatments and the drugs administered following that failure must be implicated in this outcome (2). By failing to eradicate retinoblastoma, metastatic disease ensued requiring further treatment and subsequently, AML.
The author’s report is profoundly misleading with regard to the risk of SPMs following OAC. Although the maximum period of follow-up is 12 years, the median is 2.5 years. Patients failing OAC required radiation therapy and are known to be 3 times more likely to develop additional cancers (3). We await that follow-up.
The goal of RB care is cure. This patient’s course illustrates the danger of failing to prevent metastatic disease with initial therapy. As Dr. Desjardins wrote in her recent review “ local administration [via OAC] cannot be used to treat micrometastases in advanced forms of the disease “ (4). Although metastatic RB can be treated if it develops (5), not all patients survive.
References:
1. Habib LA, Francis JH, Fabius A et al. Second primary malignancies in retinoblastoma patients treated with intra-arterial chemotherapy: the first 10 years. Br J Ophthalmol 2018; 102: 272-5.
2. Levine EG and Bloomfield CO. Leukemias and myelodysplastic syndromes secondary to drugs, radiation and environmental exposures. Semin Oncol 1982; 19: 471-84.
3. Kleinerman RA, Tucker MA, Tarone RE, et al. Risk of new cancers after radiotherapy in long-term survivors of retinoblastoma: an extended follow-up. J Clin Oncol 2005; 23: 2272-9.
4. Kassoux N, Lumbroso L, Levy-Gabriel C et al. Retinoblastoma: updates on current management. Asia-Pac J Ophthalmol 2017; 6: 290-5.
5. Dunkel IJ, Khakoo Y, Kernan NA et al. Intensive multi-modal therapy for patients with stage 4A metastatic retinoblastoma. Pediatr Blood Cancer 201; 55: 55-9.