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Radiation dose reduction during intra-arterial chemotherapy for retinoblastoma: a retrospective analysis of 96 consecutive pediatric interventions using five distinct protocols

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Abstract

Background

Intra-arterial chemotherapy (IAC) represents a mainstay of retinoblastoma treatment in children. Patients with retinoblastoma are uniquely at risk for secondary malignancies and are sensitive to the ionizing effects of radiation.

Objective

To retrospectively review a single institution’s experience with IAC for retinoblastoma and the effect of variable intra-procedural imaging techniques on radiation exposure.

Materials and methods

Twenty-four consecutive patients, with a mean age of 30.8±16.3 months (range: 3.2–83.4 months), undergoing IAC for retinoblastoma between May 2014 and May 2020 (72 months) were included. No patients were excluded. The primary outcome was radiation exposure and secondary outcomes included technical success and procedural adverse events. Technical success was defined as catheterization of the ophthalmic or meningolacrimal artery and complete delivery of chemotherapy. Each procedure was retrospectively reviewed and categorized as one of five imaging protocol types. Protocol types were characterized by uniplanar versus multiplanar imaging and digital subtraction angiographic versus roadmap angiographic techniques. Radiation exposure, protocol utilization, the association of protocol and radiation exposure were assessed.

Results

During 96 consecutive interventions, 109 ocular treatments were performed. Thirteen of the 96 (15.5%) treatments were bilateral. Ocular technical success was 106 of 109 (97.2%). All three treatment failures were successfully repeated within a week. Mean fluoroscopy time was 6.4±6.2 min (range: 0.7–31.1 min). Mean air kerma was 36.2±52.2 mGy (range: 1.4–215.0 mGy). There were two major (1.8%) complications and four (3.7%) minor complications. Of the 96 procedures, 10 (10.4%), 9 (9.4%), 13 (13.5%), 28 (29.2%) and 36 (37.5%) were performed using protocol types A, B, C, D and E, respectively. For protocol type A, mean fluoroscopy time was 10.3±6.8 min (range: 3.0–25.4 min) and mean air kerma was 118.2±61.2 mGy (range: 24.5–167.3 mGy). For protocol type E, mean fluoroscopy time was 3.1±3.2 min (range: 0.7–15.1 min) and mean air kerma was 5.4±4.2 mGy (range: 1.4–19.5 mGy). Fluoroscopy time and air kerma decreased over time, corresponding to the reduced use of multiplanar imaging and digital subtraction angiography. In the first quartile (procedures 1–24), 8 (33.3%), 7 (29.2%), 2 (8.3%), 6 (25.0%) and 1 (4.2%) were performed using protocol types A, B, C, D and E, respectively. Mean fluoroscopy time was 10.5±8.2 min (range: 2.4–28.1 min) and mean air kerma was 84.2±71.6 mGy (range: 12.8–215.0 mGy). In the final quartile (procedures 73–96), 24 (100%) procedures were performed using protocol type E. Mean fluoroscopy time was 3.5±4.0 min (range: 0.7–15.1 min) and mean air kerma was 5.0±4.3 mGy (range: 1.4–18.0 mGy), representing 66.7% and 94.1% reductions from the first quartile, respectively. Technical success in the second half of the experience was 100%.

Conclusion

Sequence elimination, consolidation from biplane imaging to lateral-only imaging, and replacing digital subtraction with roadmap angiography dramatically reduced radiation exposure during IAC for retinoblastoma without adversely affecting technical success or safety.

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Authors and Affiliations

  1. Section of Interventional Radiology, Department of Radiology, Seattle Children’s Hospital, 4800 Sand Point Way NE, M/S R-5417, Seattle, WA, 98105, USA

    Eric J. Monroe, Jeffrey Forris Beecham Chick & L. Ray Ramoso

  2. Section of Interventional Radiology, Department of Radiology, University of Washington, Seattle, WA, USA

    Eric J. Monroe & Jeffrey Forris Beecham Chick

  3. Section of Ocular Oncology, Department of Ophthalmology, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA

    Andrew W. Stacey

  4. Cancer and Blood Disorders Center, Section of Neuro-Oncology and Retinoblastoma, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA

    Nathan E. Millard & J. Russell Geyer

  5. Section of Neurointerventional Radiology, Department of Radiology, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA

    Basavaraj V. Ghodke & Danial K. Hallam

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  1. Eric J. Monroe
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  2. Jeffrey Forris Beecham Chick
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  5. J. Russell Geyer
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Correspondence to Eric J. Monroe.

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Conflicts of interest

Eric J. Monroe is a scientific adviser and speaker for Biogen. Jeffrey Forris Beecham Chick is a consultant and speaker for Guerbet and C.R. Bard. Danial K. Hallam is a consultant for Medtronic.

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Monroe, E.J., Chick, J.F.B., Stacey, A.W. et al. Radiation dose reduction during intra-arterial chemotherapy for retinoblastoma: a retrospective analysis of 96 consecutive pediatric interventions using five distinct protocols. Pediatr Radiol 51, 649–657 (2021). https://doi.org/10.1007/s00247-020-04892-x

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  • DOI: https://doi.org/10.1007/s00247-020-04892-x

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