Delayed Enucleation of Eyes with Advanced Intraocular Retinoblastoma Due to Pre-enucleation Treatment Increases Metastatic Death

Junyang Zhao, MD1*, Meirong Wei, MD2*, Guohua Liu, MD3*, Zhao Xun Feng, BSc4,5, Carlos E.

Solarte MD, FRCSC6, Bin Li, MD7, Yizhuo Wang, MD8, Chengyue Zhang, MD9, Brenda L.

Gallie, MD, FRCSC4,9,10

Authors’ affiliations

1 Department of Ophthalmology, Beijing Children’s Hospital, Capital Medical University,

National Center for Children’s Health, China.

2 Department of Ophthalmology, LiuZhou Maternal and Child Health Care Hospital, China.

3 Department of Ophthalmology, Qilu Children’s Hospital of Shan Dong University, China.

4 Department of Ophthalmology and Vision Science, Hospital for Sick Children, Toronto,

Ontario, Canada.

5 Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.

6 Department of Ophthalmology and Vision Science, University of Alberta, Edmonton, Alberta,

Canada.

7 Department of Ophthalmology, Beijing Tongren Hospital, Capital Medical University, China

8 Department of Pediatrics, Beijing Tongren Hospital, Capital Medical University, China.

9 Departments of Ophthalmology and Vision Science, Molecular Genetics and Medical

Biophysics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

10 Vision Science Research Program, Krembil Research Institute, and Techna Institute,

University Health Network, Toronto, Ontario, Canada.

Corresponding author: Junyang Zhao, 56 Nanlishi Lu, Xicheng District, Beijing, China,

100045 zhaojunyang@163.com

Running Head: Delayed Enucleation of Advanced Retinoblastoma Increases Death

Word count: /3000 words

Numbers of figures and tables: 1 consort diagram, 3 figures and 3 tables and 3 online only

figures

Key Words: retinoblastoma, enucleation, chemotherapy, pathology

Abstract (270/275)

Purpose: Advanced intraocular retinoblastoma can be cured by primary enucleation, but delay

may increase risk of metastasis. We hypothesized that delayed enucleation over a defined length

of time would increase metastatic death.

Methods: A multicenter retrospective review of eyes primarily and secondarily enucleated for

group D and E retinoblastoma. One eye enrolled per child. Primary outcome was disease-specific

survival.

Results: Studied were 554 enucleated eyes/children: 202 group D and 352 group E (International

Intraocular Retinoblastoma Classification). Primarily enucleated eyes had median <0.1 month

from diagnosis to enucleation. In comparison, pre-enucleation chemotherapy delayed enucleation

(group D median 8.4 months; group E median 2.8 months). Eyes with pre-enucleation

chemotherapy had fewer high-risk histopathology (pT3/pT4) than primarily enucleated eyes

(group D, p = .04; group E, p = .003).

Disease-specific survival (DSS) was lower with prolonged delay between diagnosis and

enucleation. Delay longer than 3.5 months (group D) and 2 months (group E) were associated

with reduced DSS (group D, p = .02; group E, p = .02). Children with group E eyes and 1 to 3

cycles of pre-enucleation chemotherapy had the same DSS as children who had primary

enucleation, but those with ≥4 cycles had lower DSS than children primarily enucleated (p

= .03). Children with high-risk eyes (pT3/pT4) after pre-enucleation chemotherapy had lower

DSS than those with high-risk eyes primarily enucleated (p = .002).

Conclusions: We showed that there is a window of opportunity in which enucleation is most

effective and no amount of pre-enucleation chemotherapy confer any survival benefit. Delay

from diagnosis to enucleation >3.5 months (group D) and >2 months (group E) increases risk of

death from metastasis.

Introduction

Retinoblastoma (RB) is the most common primary malignant intraocular tumor of the

eye.{Dimaras, 2015 #10} It accounts for 4% of all pediatric malignancies affecting one in every

16,000 to 18,000 live births.{Gallie, 1996 #7;Shields, 2006 #13;Broaddus, 2009 #12;Broaddus,

2009 #14} If discovered early, RB is one of the most treatable cancer. The International

Intraocular Retinoblastoma Classification (IIRC) predicts ≥90% chemotherapy success for

salvage of group A, B and C eyes.{Shields, 2006 #17} Even advanced RB (groups D and E)

confined to the eye can be cured by simple enucleation. However, of concern is that delayed

enucleation may increase risk of extraocular tumor extension which has limited curative options

and high mortality rate.{Gunduz, 2006 #16;Zhao, 2011 #9}

Unlike other pediatric cancers, rigorous controlled clinical trial in RB are missing for a

multitude of reasons including: low incidence of disease to interest pharmaceutical industry,

complexity with bilateral disease and vision preservation as a competing outcome measure to

cure of cancer.{Dimaras, 2015 #10} Therefore, multi-center collaboration in research is essential

to advance evidence for clinical management of RB. For this study, we assembled a database of

600 children whose eyes were primarily or secondarily enucleated for advanced intraocular RB

at 29 Chinese treatment centers. It is a continuation of our previous publication in 2011 which

identified a delay by more than 3 months from diagnosis to enucleation increases mortality for

children with group E eyes.{Zhao, 2011 #9} Since then, there has been an increasing shift

toward salvage of group D eyes by use of systemic chemotherapy{Chan, 2005 #26} and lately

intravitreal chemotherapy{Berry, 2017 #20;Munier, 2012 #18;Munier, 2012 #19}, intra-arterial

chemotherapy (IAC){Munier, 2016 #3;Yousef, 2016 #5;Shields, 2014 #4}, periocular

chemotherapy{Mallipatna, 2011 #24}, and tumor endoresection via pars plana vitrectomy{Zhao,

2018 #25}. Trial eye salvage with any of these modalities can delay enucleation. Our aim is to

re-evaluate the risk of delayed enucleation for both group D and E eyes. Secondary objective is

to study the relationship between pre-enucleation systemic chemotherapy and histopathologic

risk and their effect on long-term patient survival.

Method

Data Collection and Ethics

This was a retrospective study of all IIRC group D and E children who had primary and

secondary enucleation at 29 Chinese treatment centers between January 17, 2006 and December

26, 2010. The final follow-up date accounted in this study was December 13, 2017. Clinical

information collected include age at diagnosis, sex, disease laterality (unilateral/bilateral),

clinical staging of diseased eyes at diagnosis (IIRC), date of enucleation, neoadjuvant and

adjuvant treatments, last follow-up date, evidence of extraocular extension and date of death. The

study was approved by the ethics boards of all participating institutions, in accordance with the

Declaration of Helsinki. The list of participating centers is provided in Supplement X.

Eligibility

Of 600 children with advanced RB, none had clinical evidence of extraocular disease or

metastasis at diagnosis by lumbar puncture (LP), bone marrow aspiration, MRI or CT. For

analysis of delayed enucleation on mortality, criteria for exclusion were children who died from

reasons others than tumor metastasis and those with bilateral advanced RB (D/D, D/E, E/D or

E/E). For analysis of pre-enucleation chemotherapy (cycles or presence/absence) on mortality, in

addition to the above exclusion criteria, children with less than one complete chemotherapy cycle

(< 3 weeks) or those with pre-enucleation salvage therapy other than systemic chemotherapy

were secondarily excluded (Figure 1).

Histopathologic Assessment

All enucleated eyes were pathologically staged initially using the 7th Edition American

Joint Committee on Cancer (AJCC) pTNM based on review of hematoxylin and eosin-stained

slides. Microscopic slides included multiple section levels of the mid-globe, both calottes and

surgical margin of optic nerve. Evaluated features included the presence and extent of tumor

invasion into the optic nerve, anterior chamber, choroid and sclera. A second independent

reviewer updated the histopathology staging to 8th Ed. AJCC pTNM via review of pathology

reports and representative microscopic sections. For analysis, histopathologic risk was condensed

into two groups: low-risk (pT1 and pT2) and high-risk (pT3 and pT4). High-risk features include

massive choroidal invasion (≥3 mm), scleral invasion, episcleral invasion, retrolaminar optic

nerve invasion and invasion of optic nerve surgical margin. Table 1 summarizes the 8th Ed.

AJCC pathological staging.

Statistical Analysis

Sex, age at diagnosis, time from diagnosis to enucleation, follow-up since diagnosis,

systemic chemotherapy or not before enucleation, histopathologic risk (high vs low risk),

systemic chemotherapy or not after enucleation and IIRC classification (group D or E) were

summarized using frequency/percentage for categorical variables and median/range for

continuous variables. Baseline characteristics of children with and without pre-enucleation

chemotherapy were compared using Pearson - Chi2 test for categorical variables and Mann-

Whitney U test for continuous variables. Receiver-operating characteristic (ROC) analysis was

used to determine true positive rate (TPR) and false positive rate (FPR) for all possible cut off

values of time from diagnosis to enucleation in relation to disease-specific survival (DSS). For

any given threshold, TPR is the proportion of dead children correctly predicted, while FPR is the

proportion of living children wrongly predicted to be dead. TPR was prioritized in threshold

selection due to the greater importance of correctly identifying children at risk of metastasis.

Thresholds were used for placing children into categorical groups for survival analysis. Kaplan-

Mier (KM) survival analysis was associated to log-rank test for testing survival equality. Cox

proportional-Hazards model was used in complementary to calculate survival equality and

hazard ratio between sub-groups. Length of DSS was measured from date of diagnosis to date of

metastatic death. Patients alive were censored at last follow up. All P-values reported are two

sided and less than 0.05 indicated significance. All analysis was performed using STATA

version 15.1 (Stata Corporation) and SPSS Version 25 (IBM Corp).

Results

Patient Clinical Information

A total of 202 group D and 352 group E eyes from 554 children (335 males and 219

females) were included, with a median age of 23 months (range, 1 to 122 months) at diagnosis.

Non-studied eyes of bilateral children were IIRC group A in 27 cases, group B in 32 cases and

group C in 20 cases. Enucleation was the primary treatment for 275 eyes, while 279 eyes were

treated initially with systemic chemotherapy prior to enucleation (Table 2). 29 children also

received other pre-enucleation treatments in addition to systemic chemotherapy: IAC in 18 cases,

PPV endoresection in 6 cases, plaque radiotherapy in 3 cases, 1 case of stem cell transplantation

and 1 case of immunotherapy. Sex and age at diagnosis were not significantly different between

children with and without pre-enucleation systemic chemotherapy. The medium times from

diagnosis to enucleation were ≤ 0.1 months for primarily enucleated group D and E eyes. In

comparison, pre-enucleation chemotherapy significantly delayed enucleation (group D median

0.1 vs 8.4 months, P < .001; group E median 0-day vs 2.8 months, P < .001). Longer follow-up

was given to group E eyes with pre-enucleation chemotherapy than group E eyes primarily

enucleated (median 93 vs 84 months, P = .03). More primarily enucleated eyes had high-risk

histopathology (pT3 and pT4) than eyes treated with chemotherapy (group D 21% vs 11%, P

= .04; group E 34% vs 20%, P = .003). Related to histopathology, less children with pre-

enucleation chemotherapy received post-enucleation chemotherapy than primarily enucleated

children (group D, 14% vs 51%, P < .001; group E, 47% vs 62%, P = .03).

Pre-enucleation Chemotherapy

Median pre-enucleation chemotherapy cycles were 4 (range, 1 to 15 cycles). The

chemotherapy regimens used were either carboplatin, etoposide, and vincristine, or carboplatin,

cyclosporine, teniposide and vincristine, with doses lower than therapeutic doses previously

published{Chan, 1996 #8;Gallie, 1996 #7}. Eyes were removed when tumors progressed with no

possibility of useful vision.

Patients Died from Retinoblastoma Metastasis

22 children died from metastasis of whom among which 6 had group D and 16 had group E eyes

(Table 3). 14 14 of 22 children received pre-enucleation chemotherapy (median, 5.5 cycles). 11

11 received post-enucleation chemotherapy (median, 3 cycles). The median time from diagnosis

to enucleation was 3.7 months (range, 0 to 42.3 months). Histopathologic examination identified

5 eyes as low-risk and 17 eyes as high-risk. pTNM staging were: 4 pT1 [18%], 1 pT2b [5%], 2

pT3a [9%], 4 pT3b [18%], 2 pT3c [9%] and 9 pT4 [41%].

Primary Outcomes

ROC analysis identified time from diagnosis to enucleation >3.5 months and >2 months as cut

offs for groups D and E eyes respectively (Supplement 2 and 3). For survival analysis, group As

such, D eyes were placed into two groups: eyes enucleated <3.5 months and >3.5 months from

time of diagnosis. Group E eyes were grouped into eyes enucleated <2 months and >2 months

from time of diagnosis (Figure 2).

The association of delayed enucleation with diminished survival was confirmed. DSS

was lower if enucleation of group D eyes were delayed by longer than 3.5 months from diagnosis

(48-month DSS, 93% vs 100%; P = .02). No child with group D eye enucleated within 3.5

months died. For children with group E eyes, lower DSS was associated with delay to

enucleation longer than 2 months were (48-month DSS 97% vs 90%; HR = 3.10; P = .02).

Secondary Outcomes

510 eyes (177 group D and 333 group E) were studied for the effect of pre-enucleation

chemotherapy cycles on DSS (Figure 3). Group E eyes that received 1 to 3 cycles of systemic

chemotherapy had the same DSS as primarily enucleated eyes (48-month DSS, 97% vs 96%;

Hazard ratio = 0.77; P = .74). However, those with four or more cycles of chemotherapy had

lower DSS (48-month DSS, 86% vs 96%; HR = 3.35; P = .03). 4 group D children with pre-

enucleation chemotherapy died, while all primarily enucleated group D children survived.

However, the number is too few for survival analysis.

Of enucleated eyes with low histopathologic risk (pT1 & pT2), children with pre-

enucleation chemotherapy or not had no difference in DSS (48-month DSS, 99% vs 99%; Hazard

ratio = 0.94; P = .95; Figure 4). Despite similar adverse histopathology (primary vs secondary

enucleation % pT4, 15% vs 25%, P = .255), high-risk eyes that received systemic chemotherapy

had lower DSS than high-risk eyes primarily enucleated (48-month DSS, 59% vs 93%; HR =

5.05; P = .002).

Exploratory Outcomes

248 of 554 children received systemic chemotherapy after enucleation, with a median of

3 cycles (range, 1 to 15 cycles; Supplement 4). Not supported by published data{Kaliki, 2013

#27;Kaliki, 2011 #29;Honavar, 2002 #28}, 150 of 440 low-risk eyes received post-enucleation

chemotherapy and 16 of 114 high-risk eyes did not receive post-enucleation chemotherapy.

There was no difference in DSS between low-risk eyes with and without post-enucleation

chemotherapy (48-month DSS, 99% vs 99%; Hazard ratio = 0.49; P = 0.52). High-risk eyes

with post-enucleation chemotherapy had higher DSS compare to eyes without chemotherapy

(48-month DSS, 89% vs 49%; Hazard ratio = 0.21; P < 0.001).

Discussion

Although advanced intraocular retinoblastoma is relatively rare in developed countries, it

is the most common presentation in the developing world. In low to mid-income Asian countries,

group D and E disease constitutes 78% to 89% of all intraocular RB cases.{Chawla, 2016

#2;Gao, 2016 #3} Multi-center collaboration enabled us to the accrual one of the largest

databases of enucleated group D and E eyes. Due to lack of treatment consensus, a multitude of

institutional protocols were used across the 29 centers in this study. Family and physician may

choose to use pre-enucleation chemotherapy for various reasons including the desire for eye

salvage, parental resistance to enucleation and the belief that chemotherapy would lower risk of

metastasis.

Despite shifting emphasis toward salvage therapy, our study once again highlights the

risk to life with prolong delay to enucleation. We showed that although does not improve

survival, short duration of chemotherapy is safe. Given reported success rate of 47% to 95%

from centers worldwide {Berry, 2013 #5;Shields, 2014 #6}, there presents a window of

opportunity, 3.5 months in length, for attempted salvage of group D eyes. Group E eyes usually

present with irreversible ocular damage and high probability of adverse histopathology; thus, we

recommend urgent primary enucleation for these eyes.{Kaliki, 2015 #36;Yousef, 2015

#37;Kaliki, 2013 #35;Wilson, 2011 #30} Retinoblastoma team can take advantage of the 2-

month grace period to counsel parents who are resistant to enucleation of group E eyes. Our

study showed that enucleation ought to be performed before 3.5 months for group D eyes and 2

months for group E eyes to minimize risk of metastasis.

The AJCC pTNM staging classifies the risk of metastasis based on extent of tumor

invasion and guides post-enucleation treatment. Our study points out the unreliability of pTNM

staging with secondary enucleation. Despite having the same advanced degree of tumor invasion

(pT3 & pT4), children who received pre-enucleation chemotherapy had diminished survival

compare to primarily enucleated children. High-risk histopathology after pre-enucleation

chemotherapy may be an indicator that the tumor is chemotherapy-resistant. Therefore, treatment

with the same regimen of chemotherapy (VEC) post-enucleation may be ineffective at clearing

off resistant microscopic metastasis.

The result from this study rejects a hypothesis from our previous publication that pre-

enucleation chemotherapy masks histopathologic risk.{Zhao, 2011 #9} We found children with

low-risk eyes survive equally well with and without pre-enucleation chemotherapy, lending

evidence against the possibility of high-risk eyes disguise as low-risk through chemotherapy.

The observation was that primarily enucleated children survived better than children who

received pre-enucleation chemotherapy despite having worse histopathology. It may be that

chemotherapy have truly downstaged some high-risk eyes to low-risk, but the improvement to

overall survival may be overwhelmed by the significantly worse survival of children who

received pre-enucleation chemotherapy but still has or later developed high-risk histopathology

(Figure 4). We feel high-risk eye despite systemic chemotherapy warrants closer monitoring by

the RB team. Perhaps these children could benefit from a different regimen of post-enucleation

chemotherapy or more aggressive adjuvant treatment such as orbital irradiation. Delay to

enucleation have been shown to associated with more adverse histopathology.{Kaliki, 2015

#36;Brennan, 2015 #41} Our finding of reduced survival for secondarily enucleated high-risk

eyes further underscore the importance of timely enucleation.

Our study also confirms finding by others that post-enucleation chemotherapy should be

reserved to children with high-risk histopathology.{Chantada, 2010 #38;Chantada, 2004 #39}

For children with low-risk eyes, post-enucleation chemotherapy exposes them to toxicity without

offering any survival benefit. Four children died from tumor metastasis despite of pT1

histopathology. The eyes of these children all had focal choroidal invasion or pre-/intra-laminar

invasion but not both. The worse survival of these children compared to children with neither of

these features prompts further study into the risk profile of histopathologic features. There is also

the possibility of pathology failure in which adverse features were present in these eyes but

weren’t noticed.

Conclusion

To summarize, our study reemphasized the danger of prolonged salvage treatment in

children with advanced intraocular retinoblastoma. We showed that no amount of pre-

enucleation systemic chemotherapy confers any survival benefit. Instead, delay to enucleation

>3.5 months for group D eyes and >2 months for group E eyes from chemotherapy or other

treatment increases risk of death from metastasis. Primary enucleation remains the method that

best achieves cure and attempts to salvage vision should never be carried out at the expense of a

child’s life.

References

1. Dimaras H, Corson TW, Cobrinik D, et al: Retinoblastoma. Nat Rev Dis Primers

1:15021, 2015

2. Gallie BL, Budning A, DeBoer G, et al: Chemotherapy with focal therapy can

cure intraocular retinoblastoma without radiotherapy. Arch Ophthalmol 114:1321-8, 1996

3. Shields CL, Shields JA: Basic understanding of current classification and

management of retinoblastoma. Curr Opin Ophthalmol 17:228-34, 2006

4. Broaddus E, Topham A, Singh AD: Incidence of retinoblastoma in the USA:

1975-2004. Br J Ophthalmol 93:21-3, 2009

5. Shields CL, Mashayekhi A, Au AK, et al: The International Classification of

Retinoblastoma predicts chemoreduction success. Ophthalmology 113:2276-80, 2006

6. Gunduz K, Muftuoglu O, Gunalp I, et al: Metastatic retinoblastoma clinical

features, treatment, and prognosis. Ophthalmology 113:1558-66, 2006

7. Zhao J, Dimaras H, Massey C, et al: Pre-enucleation chemotherapy for eyes

severely affected by retinoblastoma masks risk of tumor extension and increases death from

metastasis. J Clin Oncol 29:845-51, 2011

8. Chan HS, Gallie BL, Munier FL, et al: Chemotherapy for retinoblastoma.

Ophthalmol Clin North Am 18:55-63, viii, 2005

9. Berry JL, Shah S, Bechtold M, et al: Long-term outcomes of Group D

retinoblastoma eyes during the intravitreal melphalan era. Pediatr Blood Cancer 64, 2017

10. Munier FL, Gaillard MC, Balmer A, et al: Intravitreal chemotherapy for vitreous

disease in retinoblastoma revisited: from prohibition to conditional indications. Br J Ophthalmol

96:1078-83, 2012

11. Munier FL, Soliman S, Moulin AP, et al: Profiling safety of intravitreal injections

for retinoblastoma using an anti-reflux procedure and sterilisation of the needle track. Br J

Ophthalmol 96:1084-7, 2012

12. Munier FL, Mosimann P, Puccinelli F, et al: First-line intra-arterial versus

intravenous chemotherapy in unilateral sporadic group D retinoblastoma: evidence of better

visual outcomes, ocular survival and shorter time to success with intra-arterial delivery from

retrospective review of 20 years of treatment. Br J Ophthalmol, 2016

13. Yousef YA, Soliman SE, Astudillo PP, et al: Intra-arterial Chemotherapy for

Retinoblastoma: A Systematic Review. JAMA Ophthalmol 134:584-591, 2016

14. Shields CL, Manjandavida FP, Lally SE, et al: Intra-arterial chemotherapy for

retinoblastoma in 70 eyes: outcomes based on the international classification of retinoblastoma.

Ophthalmology 121:1453-60, 2014

15. Mallipatna AC, Dimaras H, Chan HS, et al: Periocular topotecan for intraocular

retinoblastoma. Arch Ophthalmol 129:738-45, 2011

16. Zhao J, Li Q, Wu S, et al: Pars Plana Vitrectomy and Endoresection of Refractory

Intraocular Retinoblastoma. Ophthalmology 125:320-322, 2018

17. Chan HS, DeBoer G, Thiessen JJ, et al: Combining cyclosporin with

chemotherapy controls intraocular retinoblastoma without requiring radiation. Clin Cancer Res

2:1499-508, 1996

18. Kaliki S, Shields CL, Rojanaporn D, et al: High-risk retinoblastoma based on

international classification of retinoblastoma: analysis of 519 enucleated eyes. Ophthalmology

120:997-1003, 2013

19. Kaliki S, Shields CL, Shah SU, et al: Postenucleation adjuvant chemotherapy with

vincristine, etoposide, and carboplatin for the treatment of high-risk retinoblastoma. Arch

Ophthalmol 129:1422-7, 2011

20. Honavar SG, Singh AD, Shields CL, et al: Postenucleation adjuvant therapy in

high-risk retinoblastoma. Arch Ophthalmol 120:923-31, 2002

21. Chawla B, Jain A, Seth R, et al: Clinical outcome and regression patterns of

retinoblastoma treated with systemic chemoreduction and focal therapy: A prospective study.

Indian J Ophthalmol 64:524-9, 2016

22. Gao J, Zeng J, Guo B, et al: Clinical presentation and treatment outcome of

retinoblastoma in children of South Western China. Medicine (Baltimore) 95:e5204, 2016

23. Berry JL, Jubran R, Kim JW, et al: Long-term outcomes of Group D eyes in

bilateral retinoblastoma patients treated with chemoreduction and low-dose IMRT salvage.

Pediatr Blood Cancer 60:688-93, 2013

24. Kaliki S, Srinivasan V, Gupta A, et al: Clinical features predictive of high-risk

retinoblastoma in 403 Asian Indian patients: a case-control study. Ophthalmology 122:1165-72,

2015

25. Yousef YA, Al-Hussaini M, Mehyar M, et al: Predictive Value of Tnm

Classification, International Classification, and Reese-Ellsworth Staging of Retinoblastoma for

the Likelihood of High-Risk Pathologic Features. Retina 35:1883-9, 2015

26. Wilson MW, Qaddoumi I, Billups C, et al: A clinicopathological correlation of 67

eyes primarily enucleated for advanced intraocular retinoblastoma. Br J Ophthalmol 95:553-8,

2011

27. Brennan RC, Qaddoumi I, Billups CA, et al: Comparison of high-risk

histopathological features in eyes with primary or secondary enucleation for retinoblastoma. Br J

Ophthalmol 99:1366-71, 2015

28. Chantada GL, Fandino AC, Guitter MR, et al: Results of a prospective study for

the treatment of unilateral retinoblastoma. Pediatr Blood Cancer 55:60-6, 2010

29. Chantada G, Fandino A, Davila MT, et al: Results of a prospective study for the

treatment of retinoblastoma. Cancer 100:834-42, 2004

Tables and Figures

Figure 1. Consort diagram of patients in the study.

Table 1. American Joint Committee on Cancer (AJCC) pathological staging 8th Edition.

Category Criteria

pTX Unknown evidence of intraocular tumor

pT0 No evidence of intraocular tumor

pT1 Intraocular tumor(s) without any local invasion, focal choroidal invasion, OR pre- or intralaminar involvement of the optic nerve head

pT2 Intraocular tumor(s) with local invasion

pT2a Concomitant focal choroidal invasion and pre- or intralaminar involvement of the optic nerve head

pT2b Tumor invasion of stroma of iris and/or trabecular meshwork and/or Schlemm's canal

pT3 Intraocular tumor(s) with significant local invasion

pT3aMassive choroidal invasion (>3 mm in largest diameter, or multiple foci of focal choroidal involvement totaling >3 mm, or any full-thickness choroidal involvement)

pT3b Retrolaminar invasion of the optic nerve head, not involving the transected end of the optic nerve

pT3c Any partial-thickness involvement of the sclera within the inner two thirds

pT3d Full-thickness invasion into the outer third of the sclera and/or invasion into or around emissary channels

pT4

Evidence of extraocular tumor: tumor at the transected end of the optic nerve, tumor in the meningeal spaces around the optic nerve, full-thickness invasion of the sclera with invasion of the episclera, adjacent adipose tissue, extraocular muscle, bone, conjunctiva, or eyelids.

Table 2. Demographic and clinical characteristics of cohort (n = 554).

Group D Eyes (N = 202) Group E Eyes (N = 352)Pre-enucleation Chemotherapy Pre-enucleation Chemotherapy

No (N = 61) Yes (N =141) P No (N =

214) Yes (N = 138) P

SexMale 37 (61%) 88 (62%)

0.81*122 (57%) 88 (64%)

0.21*Female 24 (39%) 53 (38%) 92 (43%) 50 (36%)

Age at RB Diagnosis, months

Median 21.6 19.20.19†

26.2 24.60.32†

Range 0.8 – 75.2 1.0 – 102.5 1.6 – 121.7 1.9 – 96.9

Time from diagnosis to enucleation,

months

Median 0.1 8.4< .001†

0 2.8< .001†

Range 0 – 3.0 0.2 – 60.4 0 – 4.0 0.2 – 30.2

Follow up since RB diagnosis,

months

Median 85.0 84.90.95†

83.7 92.90.03†

Range 0 – 112.9 3.8 – 130.1 0 – 137.7 2.1 – 129.0

High-risk histopathology(pT3 & pT4) 13 (21%) 15 (11%) 0.04* 73 (34%) 27 (20%) 0.003*

Received post-enucleation chemotherapy 31 (51%) 20 (14%) < .001* 132 (62%) 65 (47%) 0.007*

* Pearson - Chi2 test† Mann-Whitney U test

Table 3. Clinical information of patients died from metastasis.

IIRCID of dead

patient

Time from diagnosis to enucleation

(month)

Pre-enucleation

Chemotherapy (cycles)

Post-enucleation

Chemotherapy (cycles)

AJCCpTNM

High-risk Histopathologic FeaturesMassive

choroidal invasion

Scleral Invasion

Episcleral

Invasion

Retro-laminar Invasion

Tumor at Resection Margin

Group D Eyes

360* 3.5 4 0 pT1 No No No No No563* 15.4 6 0 pT3a Yes No No No No497 23.9 4 0 pT3b Yes No No Yes No96 3.8 3 0 pT4 No No No Yes Yes164 10.9 6 1 pT4 Yes Yes Yes No No273 42.3 6 0 pT4 Yes Yes Yes No No

Group E Eyes

33 0 0 0 pT1 No No No No No547 3.4 4 2 pT1 No No No No No349 11.2 5 0 pT1 No No No No No343 0 0 0 pT2b No No No No No219 0 0 6 pT3a Yes No No No No125 9.2 6 3 pT3a No No No Yes No518 0 0 3 pT3b Yes No No Yes No429 19.0 9 0 pT3b Yes No No Yes No577 2.0 1 0 pT3c Yes Yes No No No528 6.2 6 0 pT3c Yes Yes No No No166 0 0 1 pT4 No No No Yes No351 0 0 4 pT4 No No No Yes Yes409 0.1 0 3 pT4 No No No Yes Yes480 0 0 12 pT4 Yes No No Yes Yes279 5.1 1 2 pT4 Yes No No Yes Yes501 19.9 6 15 pT4 No No No Yes Yes

* Patients secondarily excluded

Figure 2. (A) Disease-specific survival of group D eyes enucleated < 3.5 months and >3.5

months from time of diagnosis (B) Disease-specific survival group E eyes enucleated < 2

months and > 2 months from time of diagnosis.

Figure 3. Disease-specific survival of group E eyes with no pre-enucleation chemotherapy, 1

to 3 cycles of pre-enucleation chemotherapy and 4 or more cycles of pre-enucleation

chemotherapy.

Figure 4. Disease-specific survival of low-risk and high-risk eyes with and without pre-

enucleation chemotherapy.

Supplement 1. Receiver operating characteristic (ROC) analysis of time from diagnosis to

enucleation as a predictor of disease-specific mortality for children with group D eyes.

Time from diagnosis to enucleation

(months)

True Positive

Rate (%)

False Positive rate (%)

Time from diagnosis to enucleation

(months)

True Positive

Rate (%)

False Positive

rate (%)

Time from diagnosis to enucleation

(months)

True Positive

Rate (%)

False Positive

rate (%)

> 0.035 100 85.2 > 4.285 66.7 47.4 > 11.285 50 21.4> 0.085 100 84.2 > 4.685 66.7 46.9 > 11.435 50 20.9> 0.115 100 82.7 > 4.82 66.7 46.4 > 11.785 50 20.4> 0.15 100 79.1 > 4.985 66.7 45.9 > 12.185 50 19.9> 0.185 100 78.1 > 5.135 66.7 45.4 > 12.4 50 19.4> 0.215 100 76.5 > 5.22 66.7 44.9 > 12.885 50 18.9> 0.25 100 74.5 > 5.485 66.7 44.4 > 13.3 50 18.4> 0.285 100 73 > 5.8 66.7 43.9 > 13.35 50 17.9> 0.315 100 72.4 > 5.915 66.7 42.9 > 13.52 50 17.3> 0.35 100 71.4 > 5.965 66.7 42.3 > 13.75 50 16.8> 0.4 100 70.9 > 6.085 66.7 41.8 > 13.965 50 16.3> 0.45 100 70.4 > 6.285 66.7 41.3 > 14.15 50 15.8> 0.485 100 69.9 > 6.45 66.7 40.8 > 14.235 50 15.3> 0.55 100 69.4 > 6.515 66.7 40.3 > 14.8 50 14.8> 0.635 100 68.9 > 6.615 66.7 39.8 > 15.38 50 14.3> 0.72 100 68.4 > 6.715 66.7 39.3 > 15.58 33.3 13.8> 0.835 100 67.3 > 6.83 66.7 38.8 > 16.48 33.3 13.3> 0.915 100 66.8 > 7.03 66.7 38.3 > 17.48 33.3 12.8> 0.965 100 65.8 > 7.3 66.7 37.8 > 17.95 33.3 12.2> 1.05 100 65.3 > 7.62 66.7 36.7 > 18.4 33.3 11.7> 1.115 100 64.3 > 7.92 66.7 35.7 > 18.815 33.3 11.2> 1.15 100 63.3 > 8.185 66.7 35.2 > 19.415 33.3 10.7> 1.235 100 61.7 > 8.315 66.7 34.7 > 20.215 33.3 10.2> 1.35 100 61.2 > 8.365 66.7 34.2 > 20.9 33.3 9.7> 1.5 100 60.2 > 8.415 66.7 33.7 > 21.785 33.3 9.2

> 1.615 100 59.7 > 8.45 66.7 33.2 > 22.485 33.3 8.7> 1.65 100 58.7 > 8.52 66.7 32.7 > 23 33.3 8.2> 1.735 100 58.2 > 8.67 66.7 32.1 > 23.5 33.3 7.7> 1.815 100 57.7 > 8.785 66.7 31.6 > 23.75 33.3 7.1> 1.9 100 57.1 > 8.835 66.7 31.1 > 24.05 16.7 7.1> 2.02 100 56.6 > 8.9 66.7 30.6 > 24.985 16.7 6.6> 2.085 100 56.1 > 9.03 66.7 30.1 > 26.62 16.7 6.1> 2.315 100 55.1 > 9.15 66.7 29.1 > 29.42 16.7 5.6> 2.55 100 54.6 > 9.235 66.7 28.6 > 32.685 16.7 5.1> 2.635 100 54.1 > 9.335 66.7 28.1 > 34.1 16.7 4.6> 2.735 100 53.6 > 9.42 66.7 27.6 > 36.3 16.7 4.1> 2.87 100 53.1 > 9.57 66.7 27 > 40.315 16.7 3.6> 2.985 100 52.6 > 9.685 66.7 26.5 > 42.28 16.7 3.1> 3.05 100 52 > 9.785 66.7 26 > 42.98 0 3.1> 3.15 100 51.5 > 9.92 66.7 25.5 > 44.565 0 2.6> 3.335 100 51 > 10 66.7 25 > 48.6 0 2> 3.485 100 50.5 > 10.1 66.7 24.5 > 53.35 0 1.5> 3.6 83.3 50.5 > 10.25 66.7 24 > 56.265 0 1

> 3.735 83.3 49.5 > 10.35 66.7 23.5 > 58.95 0 0.5> 3.8 83.3 49 > 10.485 66.7 23> 3.85 66.7 49 > 10.735 66.7 22.4> 3.885 66.7 48.5 > 10.985 50 22.4> 3.935 66.7 48 > 11.15 50 21.9

Supplement 2. Receiver operating characteristic (ROC) analysis of time from diagnosis to

enucleation as a predictor of disease-specific mortality for children with group E eyes.

Time from diagnosis to enucleation

(months)

True Positive

Rate (%)

False Positive rate (%)

Time from diagnosis to enucleation

(months)

True Positive

Rate (%)

False Positive

rate (%)

Time from diagnosis to enucleation

(months)

True Positive

Rate (%)

False Positive

rate (%)

> 0.035 56.3 63.4 > 2.085 43.8 22.3 > 9 25 6.8> 0.085 56.3 60.4 > 2.115 43.8 21.7 > 9.12 25 6.5> 0.115 50 59.5 > 2.15 43.8 21.4 > 9.185 25 6.3> 0.15 50 54.2 > 2.235 43.8 21.1 > 9.315 18.8 6.3> 0.185 50 50.9 > 2.335 43.8 20.5 > 9.6 18.8 5.7> 0.215 50 49.7 > 2.42 43.8 20.2 > 9.9 18.8 5.4> 0.25 50 47.9 > 2.485 43.8 19.9 > 10.2 18.8 5.1> 0.285 50 47.6 > 2.565 43.8 19.6 > 10.8 18.8 4.8> 0.315 50 46.1 > 2.65 43.8 19.3 > 11.25 12.5 4.5> 0.35 50 45.5 > 2.72 43.8 19 > 11.7 12.5 4.2> 0.385 50 44.6 > 2.82 43.8 18.8 > 12.165 12.5 3.9> 0.415 50 43.2 > 2.885 43.8 18.5 > 12.55 12.5 3.6> 0.45 50 42 > 2.915 43.8 18.2 > 12.95 12.5 3.3> 0.485 50 41.1 > 2.95 43.8 17.9 > 13.435 12.5 3> 0.55 50 40.5 > 2.985 43.8 17.6 > 14.135 12.5 2.7> 0.615 50 40.2 > 3.165 43.8 17 > 15.665 12.5 2.4> 0.65 50 39.9 > 3.35 43.8 16.1 > 17.2 12.5 2.1> 0.685 50 39.3 > 3.485 37.5 15.8 > 17.935 12.5 1.8> 0.715 50 38.4 > 3.615 37.5 15.5 > 18.7 12.5 1.5> 0.75 50 38.1 > 3.68 37.5 15.2 > 19.435 6.3 1.5> 0.785 50 36.9 > 3.85 37.5 14.9 > 21.685 0 1.5> 0.815 50 36.6 > 4.02 37.5 14.6 > 23.9 0 1.2> 0.85 50 35.7 > 4.085 37.5 14.3 > 24.685 0 0.9> 0.885 50 34.8 > 4.135 37.5 14 > 27.385 0 0.6> 0.915 50 34.2 > 4.235 37.5 13.7 > 29.95 0 0.3> 0.95 50 33.3 > 4.315 37.5 13.4

> 1 50 32.7 > 4.4 37.5 13.1> 1.05 50 32.4 > 4.5 37.5 12.5> 1.085 50 31.5 > 4.6 37.5 12.2> 1.115 50 31 > 4.9 37.5 11.9> 1.2 50 30.7 > 5.265 31.3 11.9

> 1.285 50 30.1 > 5.415 31.3 11.6> 1.335 50 29.8 > 5.48 31.3 11.3> 1.4 50 29.5 > 5.65 31.3 11> 1.48 50 28.9 > 5.8 31.3 10.7> 1.55 50 28.6 > 5.88 31.3 10.4> 1.585 50 28.3 > 6.05 31.3 10.1> 1.615 50 27.4 > 6.185 31.3 9.8> 1.65 50 26.8 > 6.815 25 9.8> 1.72 50 26.2 > 7.565 25 9.5> 1.785 50 25.6 > 7.765 25 9.2> 1.815 50 25 > 7.95 25 8.9> 1.85 50 23.8 > 8.085 25 8.6> 1.885 50 23.5 > 8.115 25 8.3> 1.915 50 23.2 > 8.3 25 8> 1.95 50 22.9 > 8.52 25 7.7> 1.985 50 22.6 > 8.62 25 7.4> 2.035 43.8 22.6 > 8.8 25 7.1

Supplement 3. Disease-specific survival of low-risk and high-risk eyes with and without

post-enucleation chemotherapy.