Study of Treatment for Patients With Cancer of the Eye -Retinoblastoma

St. Jude Children's Research Hospital

Status and phase: Completed; Phase 3

Conditions: Retinal Neoplasm; Retinoblastoma

Treatments: Other: G-CSF; Drug: Vincristine, Carboplatin; Drug: vincristine, cyclophosphamide, and doxorubicin; Drug: Vincristine and Topotecan; Radiation: External Beam Radiation; Drug: Vincristine, Carboplatin and Etoposide; Procedure: Enucleation; Procedure: Focal Therapies; Procedure: Periocular carboplatin; Drug: Vincristine + Carboplatin + Etoposide

Study type: Interventional

Funder types: Other; NIH

Identifiers

NCT00186888

P01CA023099 (U.S. NIH Grant/Contract)

RET5

NCI-2011-01186 (Registry Identifier)

Details and patient eligibility

About

Retinoblastoma is a childhood cancer which affects the retina of the eye. The retina is the light sensitive layer of tissue that lines the back of the eyeball; sends visual messages through the optic nerve to the brain. When only one eye is affected, this is known as unilateral retinoblastoma and when both eyes are affected, it is called bilateral retinoblastoma. Treatment for retinoblastoma is individualized for each patient and is based on the form and the stage of the disease (inside the eye or has moved outside). The main goal is always to cure the cancer, and save the life of the child. Treatments are also designed with the hope of saving the vision, while completely destroying the tumor. Therapies may involve surgery, chemotherapy, radiation, and other treatments called focal treatments. Focal treatments may be laser therapy, freezing, or heat treatments meant to shrink and kill the tumor.

In this study, researchers want to investigate how different participants respond to different therapies that are individualized specifically for them. Participants will be divided into three main groups, depending on whether the disease is unilateral or bilateral, and the stage of the disease. One of the main objectives of the study is to investigate how advanced tumors in children with bilateral disease respond to a new combination of chemotherapy with topotecan and vincristine, with G-CSF support. In order to improve results, some children with very advanced disease may receive carboplatin chemotherapy given around the eye at the same time that they receive topotecan by vein. Also, because children with retinoblastoma are diagnosed so early in life and the vision may be significantly impaired, this study will investigate how children develop and how the brain adjusts and compensates for the visual deficits. Finally, this study also investigates the biology of retinoblastoma, in order to understand better how this cancer develops.

Full description

This study will determine the following:

PRIMARY OBJECTIVE:

• To estimate the ocular survival and event-free survival of bilateral disease patients with advanced intraocular retinoblastoma in either eye (R-E IV-V) responding to the vincristine/topotecan window, with alternating cycles of vincristine and carboplatin with vincristine, topotecan, and periocular carboplatin, with intensive focal treatments.

SECONDARY OBJECTIVES:

• To estimate the ocular survival of eye and event-free survival of eye of bilateral disease patients with advanced intraocular retinoblastoma in either eye (R-E IV-V) responding to the vincristine/topotecan window, with alternating cycles of vincristine and carboplatin with vincristine, topotecan, and periocular carboplatin, with intensive focal treatments.
• To estimate the ocular survival and event free survival of patients with advanced intraocular retinoblastoma (R-E IV-V) not responding to the vincristine/topotecan window, with a combination of vincristine, carboplatin, etoposide, and periocular carboplatin, with intensive focal treatments.
• To estimate the ocular survival and event free survival of eye of patients with advanced intraocular retinoblastoma (R-E IV-V) not responding to the vincristine/topotecan window, with a combination of vincristine, carboplatin, etoposide, and periocular carboplatin, with intensive focal treatments.
• To estimate the ocular survival and event-free survival of patients with early stage intraocular retinoblastoma (R-E I-III) with vincristine and carboplatin with intensive focal treatments.
• To estimate the ocular survival of eye and event-free survival of eye of patients with early stage intraocular retinoblastoma (R-E I-III) with vincristine and carboplatin with intensive focal treatments.
• To estimate the response rate of early stage eyes (R-E I-III) in patients with contralateral advanced disease treated with vincristine and topotecan.
• To estimate the ocular survival and event-free survival of early stage eyes (R-E I-III) of patients with contralateral advanced disease treated with vincristine and topotecan.
• To describe the outcome of intraocular retinoblastoma with respect to the new International Classification for Intraocular Retinoblastoma and the AJCC.
• To describe primary visual cortex function in patients with unilateral and bilateral retinoblastoma.
• To describe the cognitive, adaptive, and social/emotional development of children with retinoblastoma.
• To describe changes in the pineal gland during treatment in patients with bilateral retinoblastoma.
• To assess the relation between CYP3A4/5 genotype and the pharmacokinetics and pharmacodynamics of topotecan.
• To assess the relation between ABCG2 genotype and the pharmacokinetics and pharmacodynamics of topotecan.
• To determine if carboplatin can produce changes in cochlear function that are detectable with measurement of otoacoustic emissions.
• To evaluate the need for and feasibility of starting early intervention support during the first year after the diagnosis of retinoblastoma.

EXPLORATORY OBJECTIVES:

• To provide insight into molecular pathogenesis of retinoblastoma.
• To describe the incidence and type of germline mutations of the RB gene in patients with retinoblastoma.

Enrollment: 107 patients

Sex: All

Volunteers: No Healthy Volunteers

Inclusion criteria

• Must have newly diagnosed intraocular retinoblastoma, previously untreated. Patients previously diagnosed with unilateral retinoblastoma treated surgically (or with focal therapies), who develop asynchronous involvement of the contralateral eye, will be eligible for study.
• Must have a life expectancy of at least 8 weeks.
• Must have Performance Status (ECOG) of 0-2.
• Patients must have an adequate liver function, as defined by bilirubin less than or equal to 3 x normal, and SGOT and SGPT less than or equal to 3x normal.
• Patients must have adequate renal function as defined by serum creatinine less than or equal to 3x normal for age.
• Legal guardians must sign an informed consent indicating that they are aware of this study, its possible benefits, and toxic side effects. Legal guardians will be given a copy of the consent form.

Exclusion criteria

• Previously treated patients
• Presence of metastatic disease or orbital involvement
• Patients must not have an invasive infection at time of protocol entry.

Trial design

Primary purpose: Treatment

Allocation: Non-Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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107 participants in 3 patient groups

Stratum A

Other group

Description:

Patients with early bilateral or unilateral, or patients with bilateral that have already had the advanced eye enucleated. Treatment included vincristine and carboplatin for 8 courses, given at 3-4 week intervals. Focal therapies any time after second course can include cryotherapy, laser photocoagulation, thermotherapy, and plaque radiotherapy

Treatment:

Procedure: Focal Therapies

Procedure: Enucleation

Radiation: External Beam Radiation

Drug: Vincristine, Carboplatin

Other: G-CSF

Stratum B

Other group

Description:

Patients with bilateral disease (at least one advanced stage eye), candidate for conservative management. Treatment included window treatment with vincristine and topotecan, Followed by 3 more courses of vincristine-topotecan if they had a response to the window+ 6 courses of vincristine and carboplatin. If they do not respond to the window, they receive 6 courses of vincristine, carboplatin, and etoposide. Periocular carboplatin is also given three times, depending on whether they respond to window. External Beam Radiation 44-46 Gy administered using standard practices.

Treatment:

Drug: Vincristine + Carboplatin + Etoposide

Procedure: Periocular carboplatin

Procedure: Focal Therapies

Procedure: Enucleation

Drug: Vincristine and Topotecan

Radiation: External Beam Radiation

Drug: Vincristine, Carboplatin

Other: G-CSF

Stratum C

Other group

Description:

Patients with advanced unilateral advanced intraocular disease. First intervention is enucleation. If enucleated eye does not have disease outside the retina (low risk), no additional treatment is given. For patients whose enucleated eye shows tumor outside the retina (intermediate risk), they will receive 4 courses of vincristine, cyclophosphamide, and doxorubicin followed by G-CSF. For patients with high risk disease (involvement of the sclera, optic nerve at the level of the cut-end), treatment after enucleation is 6 courses of alternating chemotherapy with vincristine, carboplatin, etoposide (VCE) to alternate with vincristine, cyclophosphamide, and doxorubicin (VCD). High risk patients also receive external-beam radiation therapy.

Treatment:

Procedure: Enucleation

Drug: Vincristine, Carboplatin and Etoposide

Radiation: External Beam Radiation

Drug: vincristine, cyclophosphamide, and doxorubicin

Other: G-CSF