Retinoblastoma: Choosing Treatment

Successful management of retinoblastoma (RB) lies in timely diagnosis and availability of adequate resources to deliver appropriate treatment. The treatment of RB has undergone a paradigm shift with the use of chemotherapy. Various studies have shown excellent results in salvaging nearly 100% of group A, B, and C eyes; however, IAC seems to offer superior local control rates as compared with IVC for advanced intraocular retinoblastoma (Group D and E eyes). Intravitreal chemotherapy (IVitC), which delivers the highest concentration of drug in the vitreous cavity while minimizing systemic drug concentration, has emerged as an effective treatment for persistent vitreous seeding. Intravenous chemotherapy (IVC) is used widely as a first line of treatment in middle- and low-income countries (LMIC) with the move toward the use of intra-arterial chemotherapy (IAC) and intravitreal chemotherapy (IVitC) in some specialized centers. The use of subtenon carboplatin has been discontinued because of unacceptable ocular toxicities such as periorbital fat atrophy, optic nerve atrophy, and restrictive fibrosis (Jubran et al., Pediatr Blood Cancer, 67(9): e28502, 2020). The current indications for IVC in LMIC include bilateral disease, advanced disease (group C or higher), cases with suspected optic nerve or choroidal invasion on imaging studies, and financial constraints of using IAC. In contrast, in high-income countries, IAC is widely available and is preferred with the goal of vision preservation.