A Multi-institutional Feasibility Study of Intra-arterial Chemotherapy Given in the Ophthalmic Artery of Children With Retinoblastoma
Phase: PHASE1
Conditions: Unilateral Retinoblastoma
Sponsor: Children's Oncology Group

ARET12P1 
Version Date: 03/30/16 
Page 1 
Version Date: 
03/30/16 
Activated:   04/01/14 
Closed:        04/21/17
Amendment # 
2 
CHILDREN'S ONCOLOGY GROUP 
ARET12P1 
A Multi-institutional Feasibility Study of Intra-Arterial Chemotherapy Given in the Ophthalmic 
Artery of Children with Retinoblastoma 
A Limited Institution Pilot Study 
OH076 / Cincinnati Children's Hospital Medical Center (COG) 
MA036 / Dana-Farber Cancer Institute (COG) 
CT018 / Yale University (COG) 
CA824 / UCSF Medical Center-Mission Bay (COG) 
PA076 / Children's Hospital of Philadelphia (COG) 
TX041 / Baylor College of Medicine (COG) 
CA009 / Children's Hospital of Los Angeles (COG) 
TX035 / M D Anderson Cancer Center (COG) 
FL028 / University of Miami Miller School of Medicine-Sylvester Cancer Center (COG) 
GA035 / Children’s Healthcare of Atlanta-Egleston, (COG) 
IL045 / Ann and Robert H Lurie Children’s Hospital of Chicago (COG) 
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CARE IS URGED TO CONSULT WITH HIS OR HER PERSONAL PHYSICIAN OR TREATING PHYSICIAN OR VISIT THE NEAREST 
LOCAL HOSPITAL OR HEALTHCARE INSTITUTION. 
 
  
 
 

 
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TABLE OF CONTENTS 
 
SECTION 
PAGE 
STUDY COMMITTEE 
5 
ABSTRACT 
7 
EXPERIMENTAL DESIGN SCHEMA 
8 
1.0 
GOALS AND OBJECTIVES (SCIENTIFIC AIMS) 
9 
1.1 
Primary Aims 
9 
1.2 
Secondary Aims 
9 
1.3 
Correlative Science Aims 
9 
2.0 
BACKGROUND 
9 
2.1 
Introduction/Rationale for Development 
9 
2.2 
Central Reviews for Eligibility, Assessment of Responses and IA Technique 
12 
2.3 
Assessment of Vision 
12 
2.4 
Histopathology of Eyes Enucleated for Progression 
13 
3.0 
STUDY ENROLLMENT PROCEDURES AND PATIENT ELIGIBILITY 
13 
3.1 
Study Enrollment 
13 
3.1.1 
Patient Registration 
13 
3.1.2 
IRB Approval 
14 
3.1.3 
Reservation Requirements 
14 
3.1.4 
Study Enrollment 
15 
3.1.5 
Submission of Retcam Images and Retinal Drawing Prior to Study Entry 15 
3.1.6 
Timing 
16 
3.2 
Patient Eligibility Criteria 
16 
3.2.1 
Age 17 
3.2.2 
Diagnosis 
17 
3.2.3 
Evaluations required to determine eligibility 
17 
3.2.4 
Performance Level 
17 
3.2.5 
Life Expectancy 
17 
3.2.6 
Organ Function Requirements 
17 
3.2.7 
Exclusion Criteria 
18 
3.2.8 
Regulatory Requirements 
18 
4.0 
TREATMENT PROGRAM 
18 
4.1 
Overview of Treatment Plan 
18 
4.1.1 
Treatment 
18 
4.1.2 
Criteria to start subsequent cycles 
18 
4.1.3 
Interventional Radiologist Criteria 
18 
4.1.4 
Interventional Radiology Recording 
19 
4.1.5 
EUA 
19 
4.1.6 
Local Control Therapy Guidelines 
19 
4.1.7 
Supportive Care Guidelines 
19 
4.1.8 
Instructions for intra-arterial injection of melphalan 
20 
4.2 
Cycles 1, 2, and 3 (each cycle lasts 28 days) 
22 
4.2.1 
Intra-arterial Injection of Melphalan (All Cycles) 
23 
5.0 
DOSE MODIFICATIONS FOR TOXICITIES 
24 

 
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6.0 
DRUG INFORMATION 
25 
6.1 
MELPHALAN  - INTRA-ARTERIAL      (08/28/13) 
25 
7.0 
EVALUATIONS/MATERIAL AND DATA TO BE ACCESSIONED 
28 
7.1 
Required Clinical, Laboratory and Disease Evaluations 
28 
7.2 
Follow-up 
29 
7.3 
Collection of RetCam images, Retinal Drawings, Interventional Radiology 
Recording, and QA Documentation 
29 
8.0 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY 
CRITERIA 
30 
8.1 
Criteria for Removal from Protocol Therapy 
30 
8.2 
Off Study Criteria 
31 
9.0 
STATISTICAL CONSIDERATIONS 
32 
9.1 
Sample Size and Duration 
32 
9.2 
Study Design 
32 
9.3 
Gender and Minority Accrual Estimates 
38 
10.0 
EVALUATION CRITERIA 
38 
10.1 
Common Terminology Criteria for Adverse Events (CTCAE) 
38 
10.2 
Response Criteria 
38 
10.3 
Definition of Disease Progression for an Individual Eye 
39 
11.0 
ADVERSE EVENT REPORTING REQUIREMENTS 
40 
11.1 
Purpose 
40 
11.2 
Determination of Reporting Requirements 
40 
11.3 
Reporting of Adverse Events for Commercial Agents - CTEP-AERS abbreviated 
pathway 
40 
11.4 
Routine Adverse Event Reporting 
41 
12.0 
STUDY REPORTING AND MONITORING 
41 
12.1 
CDUS 
41 
12.2 
Data and Safety Monitoring Committee 
42 
13.0 
SPECIAL STUDIES SPECIMEN REQUIREMENTS 
42 
13.1 
Visual Assessment Study 
42 
13.2 
Histopathology of Eyes Enucleated for Disease Progression 
42 
14.0 
IMAGING STUDIES REQUIRED AND GUIDELINES FOR OBTAINING 
44 
14.1 
Imaging Guidelines 
44 
15.0 
GUIDELINES FOR RADIOACTIVE PLAQUE TREATMENT 
45 
15.1 
Timing 
45 
15.2 
Isotope 
45 
15.3 
Plaque Size 
45 
15.4 
Radiation Dose 
45 
15.5 
Normal tissue dosimetry 
46 
15.6 
QA Documentation 
47 
15.7 
Definition of Deviation in Protocol Performance 
48 
16.0 
OPHTHALMOLOGIC GUIDELINES 
49 
16.1 
Local Therapy 
49 

 
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APPENDIX I: CLASSIFICATION SYSTEM FOR INTRAOCULAR RETINOBLASTOMA 51 
APPENDIX II: GUIDELINES FOR TISSUE HANDLING 
52 
REFERENCES 
56 
 

 
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AGENT  
NSC#  AND 
 IND#’s 
 
Melphalan 
008806  
Exempt 

 
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The Children's Oncology Group has received a Certificate of Confidentiality from the federal government, 
which will help us protect the privacy of our research subjects. The Certificate protects against the 
involuntary release of information about your subjects collected during the course of our covered studies. 
The researchers involved in the studies cannot be forced to disclose the identity or any information collected 
in the study in any legal proceedings at the federal, state, or local level, regardless of whether they are 
criminal, administrative, or legislative proceedings. However, the subject or the researcher may choose to 
voluntarily disclose the protected information under certain circumstances.  For example, if the subject or 
his/her guardian requests the release of information in writing, the Certificate does not protect against that 
voluntary disclosure. Furthermore, federal agencies may review our records under limited circumstances, 
such as a DHHS request for information for an audit or program evaluation or an FDA request under the 
Food, Drug and Cosmetics Act. The Certificate of Confidentiality will not protect against mandatory 
disclosure by the researchers of information on suspected child abuse, reportable communicable diseases, 
and/or possible threat of harm to self or others 
 
ABSTRACT 
Retinoblastoma is the most common primary intra-ocular malignancy in childhood. Two-thirds of children 
diagnosed with retinoblastoma have disease in one eye only (unilateral disease). About 85% of the children 
with unilateral retinoblastoma have advanced disease at the time of diagnosis and the standard of care in 
these children is enucleation of the eye. Although this procedure is curative in over 90% of children, there 
is a desire among many families to preserve the eye. Furthermore, some of these eyes have useful vision 
that is lost with enucleation. 
 
Systemic chemotherapy in combination with local ophthalmic therapy has been used with the goal of 
avoiding enucleation. Studies have shown that chemoreduction and local therapy do not provide effective 
control in patients with advanced unilateral disease and a high proportion of these patients eventually 
require either external beam radiation therapy or enucleation.  
 
Localized delivery of chemotherapy directly into the ophthalmic artery may increase ocular salvage and 
result in less toxicity than systemic chemotherapy. However, this complex technique requires a high level 
of expertise that is currently available only at large pediatric centers with excellent infrastructure. Several 
institutions within the United States and in other countries are currently using this modality. As more 
centers engage in this treatment toxicities are being reported, including acute vitreous hemorrhage, 
chorioretinal atrophy, and ophthalmic artery stenosis. A properly designed prospective study to evaluate 
the feasibility and efficacy of this procedure in the context of a multi-institutional study is a critical next 
step towards the goal of establishing guidelines for the safe implementation of the intra-arterial technique 
across COG sites.  
 
ARET12P1 is designed to test the feasibility of delivering melphalan directly into the ophthalmic artery in 
children with newly diagnosed unilateral retinoblastoma with Group D disease, by the International 
Classification System for Intraocular Retinoblastoma, who would otherwise be considered for enucleation. 
Response to therapy and toxicity of the regimens will also be assessed. This study will be the first attempt 
to perform a well-conducted clinical trial of intra-arterial therapy for unilateral retinoblastoma with 
emphasis on feasibility and efficacy in a multi-institutional trial. 
 
 

 
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EXPERIMENTAL DESIGN SCHEMA 
 
Diagnosis 
On Study 
Cycle 1 
(IA Melphalan Injection 1 + Interventional Radiology 
Recording) 
Local Control Therapy 
Follow Up  
End of Protocol Therapy 
Cycle 2 
(IA Melphalan Injection 2) 
Cycle 3 
(IA Melphalan Injection 3) 
MRIs of brain and orbits  
EUA w/RETCAM + Local Control therapy 
Off Protocol Therapy 
EUA w/RETCAM 
(to be used for response determination) 
Progressive Disease 
EUA w/RETCAM + Local Control therapy 
EUA w/RETCAM + Local Control therapy 

 
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1.0 
GOALS AND OBJECTIVES (SCIENTIFIC AIMS) 
1.1 
Primary Aims 
1.1.1 
To study the feasibility of delivering melphalan directly into the ophthalmic artery 
in children with newly diagnosed unilateral Group D retinoblastoma, who would 
otherwise be considered for enucleation.  
1.2 
Secondary Aims 
1.2.1 
To estimate the ocular salvage rate after treatment with intra-arterial melphalan in 
children with newly diagnosed unilateral retinoblastoma with Group D disease. 
1.2.2 
To evaluate the toxicities and adverse events associated with delivering multiple 
doses of intra-arterial chemotherapy. 
1.2.3 
To evaluate vision outcomes in children treated with intra-arterial chemotherapy. 
1.2.4 
To monitor the rate of the development of metastatic disease while on protocol 
therapy 
1.3 
Correlative Science Aims 
1.3.1 
To evaluate the effects of intra-arterial therapy on the histopathology of eyes 
enucleated for progression. 
 
2.0 
BACKGROUND 
2.1 
Introduction/Rationale for Development 
Retinoblastoma is the most common primary intra-ocular malignancy in childhood. Two-
thirds of children diagnosed with retinoblastoma have disease in one eye only (unilateral 
disease). About 85% of the children with unilateral retinoblastoma have advanced disease 
at the time of diagnosis and the standard of care in these children is enucleation of the eye. 
Although this procedure is curative in over 90% of children, there is a desire among many 
families to preserve the eye. Furthermore, some of these eyes have useful vision that is lost 
with enucleation. 
 
Systemic chemotherapy in combination with one or more of other therapies such as 
cryotherapy and laser therapy have been used as alternative treatments for the prevention 
of metastatic disease and local recurrence and preservation of vision. External beam 
radiation or radioactive plaque therapy have also been used for effective orbital and 
intraocular disease control. Shields et al. have shown that chemoreduction alone in patients 
with advanced unilateral disease does not provide effective control of disease; in their study 
all such patients eventually required either external beam radiation therapy or enucleation.1 
Furthermore ocular oncologists strongly feel that to treat a patient with intraocular tumor(s) 
with systemic chemotherapy of several months duration with subsequent toxicities is not 
optimal. 
 
In countries like Japan where there is particular emphasis by the families to preserve the 
globe, attempts were made by investigators to inject chemotherapy directly into the internal 
carotid artery with an inflated balloon above the origin of the ophthalmic artery.2 The aim 
was to facilitate chemotherapy to enter the ophthalmic artery. The drug they chose for intra-
arterial chemotherapy was melphalan based on in vitro studies.3 Using this technique 
Suzuki and Kaneko reported 563 injections in 187 patients with a low rate of complications. 
All of the eyes treated also received concomitant therapy with either hyperthermia, external 
beam radiation and/or, in 1 patient, intravitreal injections of melphalan. Investigators in the 
US have further developed the technique by performing selective cannulation of the 

 
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ophthalmic artery to deliver chemotherapy.4-7 In the most recent update, 95 eyes in 78 
patients (30 unilateral, 48 bilateral) were treated with intra-arterial chemotherapy.7 The 
mean number of procedures was 3.2 per patient and 3.1 per eye. Chemotherapy included 
melphalan alone, or in combination with topotecan, and/or carboplatin. The ocular salvage 
rate was 81.7% for the 39 previously untreated eyes and 58.4% for the 56 R-E V eyes that 
had failed prior treatments. Catheterization was successful in 98.5% of patients. The ocular 
salvage rate was 81.7% for the 39 previously untreated eyes and 58.4% for the 56 R-E V 
eyes that had failed prior treatments. Catheterization was successful in 98.5% of patients. 
Neutropenia developed after 29 of 255 IA sessions (11.4%) and of these only 8 were grade 
4; only one child required admission for fever and neutropenia. No child required blood 
products. All the children are alive including 2 who developed metastases, 7 and 9 months 
after enucleation. 
 
Impressive as these results are, the heterogeneity of treatments administered as well as the 
lack of a proper study design to assess toxicity and outcomes in a prospective manner leave 
many questions unanswered. However several centers in the United States have started 
performing this procedure. Using this complex technique requires a high level of expertise 
that is only available at large pediatric centers with excellent infrastructure. Furthermore, 
as more centers are engaging in this treatment ocular toxicities are being reported, 
including acute vitreous hemorrhage, chorioretinal atrophy, and ophthalmic artery 
stenosis.8,9,10 
 
Therefore, a properly designed prospective study is felt to be critical. The COG Rare 
Tumors committee sponsored a meeting of ophthalmologists, interventional radiologists 
and pediatric oncologists from 10 large pediatric centers to design a study that could 
eventually establish guidelines for the safe implementation of the intra-arterial technique 
and to evaluate its feasibility and efficacy in the context of a multi-institutional study. It 
was agreed that patients with Group D disease, by the International Classification System 
for Intraocular Retinoblastoma, would be the appropriate treatment population and to avoid 
Group E eyes because of the possible increased incidence of high-risk factors for metastasis 
in these advanced tumors.11,12 On this study, there will be a rapid central review of 
RETCAM images at the time of enrollment and at the end of the 3rd cycle. Central review 
has worked very well within COG in the past. Of the 7 patients excluded from the study 
ARET0331 which was opened for patients with Group B disease, 6 had either Group C or 
D disease and therefore would have been significantly under-treated if they were enrolled 
on ARET0331.  
 
Melphalan is an ideal drug for this technique. It does not need to be metabolized to an 
active agent and the half life of melphalan oral formulation is 90 minutes vs.75 
minutes for the intravenous formulation. It is rapidly excreted mainly through the non-
renal route. The dose used for intra-arterial injections for retinoblastoma is low and its 
efficacy in this setting has been proven by the above studies. In the largest and most recent 
report on IA therapy in children with retinoblastoma an initial dose finding phase was 
described where efficacy and toxicity were assessed during examination under anesthesia 
every 3-4 weeks after treatment.7 The recommended doses of melphalan from this study 
were 3 mg for patients between 6 and 12 months of age, 4 mg between the ages of 12 
months and 24 months and 5 mg between 24 months and 36 months. Initial drug dosage 
was based on age which provides an estimate of the ocular size.13,14 However upon further 
review of the literature addressing growth in globe volume, we feel that consistent and 
uniform dosing across the ages will be obtained with 3 mg (6 to 11.99 months), 3.5 mg 

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2.2 
Central Reviews for Eligibility, Assessment of Responses and IA Technique 
Through previous COG protocols a central review mechanism was set up to review 
eligibility based on initial stage. In this study this mechanism will be used not only to 
confirm eligibility but also response at the end of the 3rd cycle. Three ophthalmologists 
with one alternate will be on the review panel to assess eligibility and three interventional 
radiologists with one alternate will review interventional radiology recordings of the first 
IA injection on every patient. The purpose of these reviews is to assess the technique of 
the individual interventional radiologist and the anatomy of the vasculature involving the 
ophthalmic artery. The reviewers may suggest a dose modification after studying the 
vasculature of the ophthalmic artery.  
 
Several institutions within the United States and institutions in other countries (Italy, 
Switzerland, and Argentina) are using this modality. However this proposal will be the 
first attempt to perform a well-conducted clinical trial with emphasis on feasibility and 
efficacy in a multi-institutional trial. 
 
There is an urgent need for the development of a prospective multi-institutional trial to test 
the feasibility of the technique in a cooperative group setting which may serve as a prelude 
to future studies with agents other than melphalan and more importantly help refine the 
delivery technique so the local toxicities can be minimized.15-17 
 
2.3 
Assessment of Vision 
Historically and in a number of treating centers advanced unilateral retinoblastoma (Groups 
D/E) is managed with primary enucleation. As such any salvaged eye would have an 
improved visual acuity over controls.  
 
Objective testing of vision in pre-verbal children at baseline is possible with methods such 
as Teller visual acuity. This approach requires a specialty trained technician monitoring the 
response of a cooperative child, as various striped cards are presented to the infant. Given 
the need to patch the normal eye in a newly diagnosed infant with unilateral disease many 
children will not be cooperative for this test and the measured acuity may be compromised. 
In some centers Teller vision assessment is not readily available and the quality of the 
technical support may vary. Requiring such a visual assessment at baseline may exclude 
some centers from participation or delay therapy from being initiated. Also the quality of 
data across institutions using this technique may render the results inconclusive. 
 
Prior reports addressing vision in this cohort have looked at final visual acuity not the 
variance of vision from study entry to exit. In most cases the affected eye will present and 
remain amblyopic. The average age at study entrance will be 22-23 months but this will 
range on average from 6 months to 4 years. On this study, we will be assessing visual acuity 
once a year for 4 years, starting 1 year after completion of protocol therapy; most children 
should be between 3-5 years of age.  
 
Options for testing visual acuity in the 3-5 year age range include: Snellen letters, Snellen 
numbers, Tumbling E, HOTV, and Allen figures. Each test is listed in decreasing order of 
cognitive difficulty. Given these criteria and age range we will be using the single surround 
HOTV – known as the amblyopia treatment study visual acuity protocol. The approach has 
been validated and has a high testability in 3-7 year olds. It is standardized and has been 
used in multi-center trials for amblyopia treatment.  
 

 
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We have consulted Dr M Repka a pediatric ophthalmologist with expertise in this field 
who has recommended the above testing method. 
 
2.4 
Histopathology of Eyes Enucleated for Progression 
Eyes enucleated for progression will be processed and sent for central histopathology 
review by Dr Patricia Chevez-Barrios who is a leading expert in the pathology of 
Retinoblastoma. This will be the first prospective study of systematic assessment of 
histopathology features of eyes that are enucleated for progression following IA therapy.  
 
A previous retrospective study of 8 eyes treated with intra-arterial chemotherapy for 
retinoblastoma has shown ocular complications that include thromboembolic events. In 
this study the eyes were enucleated for tumor viability, neovascular glaucoma, anaphylactic 
reaction from IAC, and persistent retinal detachment with poor visualization of the tumor.18 
The tumor response ranged from minimal (n=1) to moderate (n=1) to extensive (n=4) to 
complete regression (n=2). Viable vitreous seeds (n=4 eyes), invasion into the optic nerve 
(n=3), reaching the lamina cribrosa in 2 cases, and invasion into the choroid (n=1) were 
observed. Histopathologic evidence of ischemic atrophy involving the outer retina and 
choroid was found in 4 eyes. One eye had extensive choroidal and outer retinal atrophy. 
This case showed orbital vascular occlusion and subendothelial smooth muscle 
hyperplasia. Intravascular birefringent foreign material was observed in 5 cases within 
occluded vessels, stimulating a granulomatous inflammatory response. The foreign 
material comprised cellulose fibers (n=3), synthetic fabric fibers (n=1), or unknown 
composition (n=2). Thrombosed blood vessels were identified in 5 eyes and involved 
ciliary arteries in the retrobulbar orbit (n=5), scleral emissarial canals (n=1), small 
choroidal vessels (n=1), and central retinal artery (n=1).18  
 
 
3.0 
STUDY ENROLLMENT PROCEDURES AND PATIENT ELIGIBILITY 
3.1 
Study Enrollment 
 
3.1.1 
Patient Registration 
Prior to enrollment on this study, patients must be assigned a COG patient ID 
number.  
 
This number is obtained via the COG Registry system once authorization for the 
release of protected health information (PHI) has been obtained. The COG patient 
ID number is used to identify the patient in all future interactions with COG. If you 
have problems with the registration, please refer to the online help.  
 
In order for an institution to maintain COG membership requirements, every newly 
diagnosed patient needs to be offered participation in ACCRN07, Protocol for the 
Enrollment on the Official COG Registry, The Childhood Cancer Research Network 
(CCRN), or APEC14B1, Project:EveryChild A Registry, Eligibility Screening, 
Biology and Outcome Study.  
 
A Biopathology Center (BPC) number will be assigned as part of the registration 
process. Each patient will be assigned only one BPC number per COG Patient ID. 

 
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For additional information about the labeling of specimens please refer to the 
Pathology and/or Biology Guidelines in this protocol.  
 
3.1.2 
IRB Approval 
Local IRB/REB approval of this study must be obtained by a site prior to enrolling 
patients. Sites must submit IRB/REB approvals to the NCI’s Cancer Trials Support 
Unit (CTSU) Regulatory Office and allow 3 business days for processing. The 
submission must include a fax coversheet (or optional CTSU IRB Transmittal 
Sheet) and the IRB approval document(s). The CTSU IRB Certification Form may 
be submitted in lieu of the signed IRB approval letter. All CTSU forms can be 
located on the CTSU web page (https://www.ctsu.org). Any other regulatory 
documents needed for access to the study enrollment screens will be listed for the 
study on the CTSU Member’s Website under the RSS Tab.  
 
IRB/REB approval documents may be faxed (1-215-569-0206), 
E-mailed (CTSURegulatory@ctsu.coccg.org) or mailed to the CTSU Regulatory 
office.  
 
When a site has a pending patient enrollment within the next 24 hours, this is 
considered a “Time of Need” registration. For Time of Need registrations, in 
addition to marking your submissions as ‘URGENT’ and faxing the regulatory 
documents, call the CTSU Regulatory Helpdesk at: 1-866-651-CTSU. For general 
(non-regulatory) questions call the CTSU General Helpdesk at: 1-888-823-5923. 
 
3.1.3 
Reservation Requirements 
Patient enrollment for this study will be facilitated using the Slot-Reservation 
System in the Oncology Patient Enrollment Network (OPEN). Prior to discussing 
protocol entry with the patient, site staff must use the CTSU OPEN Slot 
Reservation System to ensure that a slot on the appropriate protocol stratum is 
available for the patient. Once a slot- reservation confirmation is obtained, site staff 
may then proceed to enroll the patient to this study.  
 
A reservation can be made by following the steps below: 
 
1) Log in to https://open.ctsu.org/open/ using your CTEP IAM user name and 
password.  
2) In order to make a reservation, the patient must have an OPEN patient number. 
Click on the ‘Slot Reservation’ tab to create an OPEN patient number, under 
‘Patients’. 
3) Using the OPEN patient number ‘RESERVE’ a slot for that patient.  
4) On the ‘Create Slot Reservation’ page, select the Protocol Number, enter the 
COG Patient ID, and choose the required stratum (if applicable) in order to 
obtain a reservation. 
 
Refer to the ‘SITE – Slot Reservation Quick Reference’ guide posted under 
the ‘Help’ tab in OPEN for detailed instructions:  
https://www.ctsu.org/readfile.aspx?fname=OPEN/OPEN_SlotReservation_Q
uickReference_SiteUserGuide_102612.pdf&ftype=PDF 
 

 
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Prior to obtaining informed consent and enrolling a patient, a reservation must be 
made following the steps above. Reservations may be obtained 24 hours a day 
through the OPEN system.  
 
3.1.4 
Study Enrollment 
Patient enrollment will be facilitated using the Oncology Patient Enrollment 
Network (OPEN). All site staff will use OPEN. OPEN is a web-based registration 
system available on a 24/7 basis. It is integrated with the CTSU Enterprise System 
for regulatory and roster data and, upon enrollment, initializes the patient position 
in the Rave database. The system can be accessed by entering credentials at 
https://www.ctsu.org and clicking on the OPEN tab, or by entering credentials at 
the OPEN portal URL https://open.ctsu.org.  
 
Prior to accessing OPEN, site staff should verify the following: 
 
• 
All eligibility criteria have been met within the protocol stated timeframes. 
Site staff should use the registration forms provided on the group web site 
as a tool to verify eligibility. 
• 
All patients have signed an appropriate consent form and HIPAA 
authorization form (if applicable). 
 
Access requirements for OPEN: 
 
• 
Site staff will need to be registered with CTEP and have a valid and active 
CTEP-IAM account. This is the same account (user id and password) used 
for credentialing in the CTSU members' web site.  
• 
To perform registrations, the site user must have been assigned the 
'Registrar' role on the relevant Group or CTSU roster.  
 
Note: The OPEN system will provide the site with a printable confirmation of 
registration and treatment information. Please print this confirmation for your 
records. 
 
Further instructional information is provided on the CTSU members' web site 
OPEN tab or within the OPEN URL (https://open.ctsu.org). For any additional 
questions 
contact 
the 
CTSU 
Help 
Desk 
at 
1-888-823-5923 
or 
ctsucontact@westat.com. 
 
3.1.5 
Submission of Retcam Images and Retinal Drawing Prior to Study Entry 
RetCam images and retinal drawings obtained from the diagnostic EUA MUST be 
submitted to IROC Rhode Island (QARC) within 7 days of the procedure for rapid 
central review. This is for confirmation of the diagnosis of Group D disease. The 
ARET12P1 Diagnostic EUA Eligibility Review Transmittal form must be 
included with the RetCam images and retinal drawings. This form can be found on 
the IROC Rhode Island (QARC) website, www.qarc.org. The central review 
committee will require a maximum of 7 days to return the review to the individual 
institution. Central review confirmation of Group D disease MUST be obtained 
before enrollment. See Section 7.3.2. 
 

 
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3.1.6 
Timing 
Patients must be enrolled within 14 days of diagnostic EUA.  
 
The date protocol therapy is projected to start must be no later than five (5) 
calendar days after the date of study enrollment.  
 
All clinical and laboratory studies to determine eligibility must be performed 
within 7 days prior to enrollment unless otherwise indicated in the eligibility 
section below.  
 
MRI of the brain and orbits must be performed within 14 days prior to 
enrollment.  
 
3.2 
Patient Eligibility Criteria 
 
Important note: The eligibility criteria listed below are interpreted literally and 
cannot be waived (per COG policy posted 5/11/01). All clinical and laboratory data 
required for determining eligibility of a patient enrolled on this trial must be available 
in the patient's medical/research record which will serve as the source document for 
verification at the time of audit.  
 
All clinical and laboratory studies to determine eligibility must be performed within 
7 days prior to enrollment unless otherwise indicated. Laboratory values used to 
assess eligibility must be no older than seven (7) days at the start of therapy. 
Laboratory tests need not be repeated if therapy starts within seven (7) days of 
obtaining labs to assess eligibility. If a post-enrollment lab value is outside the limits 
of eligibility, or laboratory values are > 7 days old, then the following laboratory 
evaluations must be re-checked within 48 hours prior to initiating therapy: CBC with 
differential, bilirubin, ALT (SGPT) and serum creatinine. If the recheck is outside 
the limits of eligibility, the patient may not receive protocol therapy and will be 
considered off protocol therapy. Imaging studies, if applicable, must be obtained 
within 2 weeks prior to enrollment (repeat the tumor imaging if necessary). 
 
See Section 7.1 for required studies to be obtained prior to starting protocol therapy. 
 
 
 

 
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INCLUSION CRITERIA 
 
3.2.1 
Age  
6 months or greater at time of study enrollment. 
 
3.2.2 
Diagnosis  
Newly diagnosed patients with Unilateral Group D Retinoblastoma (see Appendix 
I: Classification System for Intraocular Retinoblastoma.) 
 
3.2.3 
Evaluations required to determine eligibility 
• 
MRI (or CT If MRI is not available) of the brain must be performed within 
14 days prior to study entry 
• 
Diagnostic EUA must be performed within 14 days prior to study entry.  
• 
Rapid central review confirmation of Group D disease based on RetCam 
images from diagnostic EUA must be obtained before starting treatment. 
 
3.2.4 
Performance Level  
Patients must have a performance status corresponding to ECOG scores of 0, 1 or 
2. See https://members.childrensoncologygroup.org/prot/reference_materials.asp 
under Standard Sections for Protocols.  
 
3.2.5 
Life Expectancy 
Patients must have a life expectancy of ≥ 8 weeks. 
 
3.2.6 
Organ Function Requirements 
3.2.6.1 
Patients must have adequate renal function, defined as: 
- Creatinine clearance or radioisotope GFR ≥ 70 mL/min/1.73 m2 or 
- A serum creatinine based on age/gender as follows: 
 
Age 
 
Maximum Serum 
Creatinine (mg/dL) 
 
Male 
Female 
1 month to < 6 months 
0.4 
0.4 
6 months to < 1 year 
0.5 
0.5 
1 to < 2 years 
0.6 
0.6 
2 to < 6 years 
0.8 
0.8 
6 to < 10 years 
1 
1 
10 to < 13 years 
1.2 
1.2 
13 to < 16 years 
1.5 
1.4 
≥ 16 years 
1.7 
1.4 
The threshold creatinine values in this Table were derived from the Schwartz 
formula for estimating GFR (Schwartz et al. J. Peds, 106:522, 1985) utilizing 
child length and stature data published by the CDC. 
 
3.2.6.2 
Patients must have adequate liver function, defined as: 
- 
Total bilirubin ≤ 1.5 x upper limit of normal (ULN) for age, and 
- 
SGPT (ALT) < 2.5 x upper limit of normal (ULN) for age. 
 

 
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3.2.7 
Exclusion Criteria 
 
3.2.7.1 
Patients with bilateral disease 
 
3.2.7.2 
Unilateral retinoblastoma with Group A, B, C, or E eyes 
 
3.2.7.3 
Prior chemotherapy or radiation therapy for this disease (laser and 
cryotherapy are allowed and are not considered exclusion criteria) 
 
3.2.7.4 
Clinical or neuroimaging evidence of extraocular disease or orbital 
optic nerve involvement 
 
3.2.8 
Regulatory Requirements 
 
3.2.8.1 
All patients and/or their parents or legal guardians must sign a written 
informed consent. 
 
3.2.8.2 
All institutional, FDA, and NCI requirements for human studies must be 
met. 
 
 
4.0 
TREATMENT PROGRAM 
Timing of protocol therapy administration, response assessment studies, and surgical 
interventions are based on schedules derived from the experimental design or on established 
standards of care. Minor unavoidable departures (up to 72 hours) from protocol directed therapy 
and/or disease evaluations (and up to 1 week for surgery) for valid clinical, patient and family 
logistical, or facility, procedure and/or anesthesia scheduling issues are acceptable per COG 
administrative Policy 5.14 (except where explicitly prohibited within the protocol). 
 
4.1 
Overview of Treatment Plan 
4.1.1 
Treatment 
Eligible patients will receive 1 intra-arterial injection (IA) of melphalan every 21-
30 days. Injections may be repeated every 21-30 days (up to a maximum of 3 
cycles) assuming the patients meets the criteria to begin the next cycle. 
 
4.1.2 
Criteria to start subsequent cycles 
All Cycles: ANC ≥ 1000/µL, platelets ≥ 100,000/µL, Hemoglobin ≥ 8 g/dL, 
SGPT (ALT) < 2.5 x upper limit of normal (ULN) for age. 
 
Cycle 2: Central review comments based on the interventional radiology recording 
from Cycle 1 must be obtained for each patient before starting Cycle 2 treatment. 
 
4.1.3 
Interventional Radiologist Criteria 
Site requirements for the interventional radiologist participating in the study (if 
you use a backup interventional radiologist he/she must meet the same 
requirements) 

 
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1. At least 2 years post fellowship 
2. Prior experience in performing at least 20 procedures above the skull 
base in children < 6 years 
3. Experience with flow-directed catheters 
4. New participant must submit reports of the 20 procedures for review 
by the central INR committee 
a. Submit reports to Dr. Darren Orbach at 
Darren.Orbach@childrens.harvard.edu  
5. The designated interventional radiologist who meets the above criteria 
should be the one to perform all interventional radiology procedures 
for intra-arterial chemotherapy. 
6. The designated institutional interventional radiologist from each 
institution is strongly encouraged to visit Dr. Pierre Gobin to observe 
the technique prior to enrolling patients on the protocol. 
 
4.1.4 
Interventional Radiology Recording 
Interventional radiology recordings of the first IA melphalan injection must be 
taken during the procedure and sent to IROC Rhode Island (QARC)  for central 
review within 14 days of the procedure. If this recording is not submitted within 
the 14 day window, the subject will remain on study for feasibility, but will be 
considered inevaluable for response and salvage.  
 
4.1.5 
EUA 
An examination under anesthesia (EUA) must be performed at the following time 
points: 
1. Up to 14 days prior to enrollment (diagnostic EUA). EUA does not 
have to be repeated prior to the first IA injection.  
2. Up to 7 days prior to each subsequent IA injection. 
3. 14-28 days after the final IA injection. 
4. As clinically indicated. 
 
Patients with evidence of disease progression (see Section 10.3 for definitions) at 
the time of EUA will be removed from protocol therapy at specified time points. 
RETCAM images and retinal drawings of the  two (2) most recent EUAs should 
be sent for central review within 7 days of the EUA showing disease progression. 
 
4.1.6 
Local Control Therapy Guidelines 
Local control (cryotherapy, laser therapy, or plaque therapy) will be performed as 
needed per ophthalmologist’s discretion at the time of EUA. See Section 15.0 and 
Section 16.0 for local control therapy guidelines. Once the 3 doses of IA melphalan 
have been administered, patients will continue to receive local control (laser, 
cryotherapy, or plaque) as needed per ophthalmologist’s discretion. Radiation 
exposure during the interventional radiology procedures will be recorded. 
Variations in the timing or technique of delivering local therapies will not be 
considered a violation of the protocol.  
 
4.1.7 
Supportive Care Guidelines 
Appropriate antibiotics, blood products, anti-emetics, fluids, electrolytes and 
general supportive care are to be used as needed per institutional guidelines. 

 
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For COG Supportive Care Guidelines see:  
https://members.childrensoncologygroup.org/prot/reference_materials.asp 
under 
Standard Sections for Protocols. 
 
4.1.8 
Instructions for intra-arterial injection of melphalan 
The injection must be completed within 60 minutes of product reconstitution. 
 
Cerebral angiography in infants poses unique technical challenge, with potential risk 
of severe morbidity to both access and target vessels, as well as risk of possible severe 
neurological morbidity, arising quickly.  
 
Fastidious technique to reduce patient radiation exposure is particularly critical when 
treating infants with retinoblastoma, as the infant brain typically absorbs 50% of the 
incident skin radiation dose. Digital subtraction angiography exposes patients to a 
much higher radiation dose than does live fluoroscopy. As such, formal angiographic 
runs should be minimized as much as possible, to a degree that is still consistent with 
safely performing the procedure and ensuring normal runoff to the brain and eye in 
all arterial branches. Roadmaps and live fluoroscopy are to be generally preferred. 
 
For a unilateral treatment, a total skin dose of under 100 mGy (frontal and lateral 
planes summed) can be expected.  
 
The procedure is performed under general anesthesia with endotracheal intubation.  
 
Oxymetazoline 0.05% (two sprays) is sprayed in the nostril on the treatment side, to 
reduce the blush from the nasal mucosa and risk of epistaxis.  
 
Phenylephrine hydrochloride 10% ophthalmic solution (two drops) may be spread over 
the skin of the forehead above the eye on the treatment side, to vasoconstrict the skin and 
reduce the risk of skin erythema. (optional) 
 
Heparin is administered intravenously at 70 International Units/Kg.  
 
Heparin is administered after femoral artery puncture at the time of microcatheter 
manipulation inside the arteries 
 
One femoral artery (alternatively right/left) is punctured with a 3F micropuncture system 
and a 3F femoral sheath is placed.  
 
A straight microcatheter such as a Marathon (EV3 Irvine, CA) or a Magic 1.5 (Balt, 
Montmorency, France) is advanced over a micro-guide wire such as the Mirage (EV3 
Irvine, CA) into the internal carotid artery. A 4F guide catheter is usually not necessary. 
A cerebral angiogram is performed.  
 
The microcatheter is placed at the origin of the ophthalmic artery, without catheterizing 
it. Then, imaging of the ophthalmic artery is performed to visualize the angioanatomy, the 
choroid blush, and that there is no reflux of contrast into the internal carotid. To minimize 
radiation exposure, this last imaging is performed by subtracted fluoroscopy rather than 
angiography.  
 

 
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If the ophthalmic artery is not appropriate for selective catheterization, one may 
catheterize the middle meningeal artery and perform a selective angiogram to find if the 
orbital branch is large enough for catheterization and intra-arterial injection.  
 
The chemotherapy drug should be prepared according to Section 6.1 prior to delivery of 
the medication to the angio suite under sterile conditions. The drug is then injected 
manually by repeated small bolus –pulsatile injection- at a rate of 1 mL/minute. 
 
After completion of administration of the drug flush the catheter while still in place with 
0.5 ml normal saline. 
 
All of the drug is expected to reach the ophthalmic artery. 
 
Operators should perform intermittent contrast or fluoroscopy to ensure that the catheter 
has not moved, or that spasm has not occurred. 
 
After drug delivery, another substracted fluoroscopy of the ophthalmic artery is 
performed; the microcatheter is pulled into the internal carotid artery and another internal 
carotid angiogram performed.  
 
The microcatheter is removed, an ACT is performed and if < 2.5 baseline the sheath is 
removed and hemostasis of the femoral artery obtained with manual compression for 10-
20 minutes.  
 
After awakening, the child should be monitored for at least 6 hours post procedure before 
being discharged home for observation.  
 

 
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4.2 
Cycles 1, 2, and 3 (each cycle lasts 28 days) 
 
Melphalan: IA 
Day 1 
Dose: Melphalan dose will be adjusted to age: 
• 
Patients = 6 - 11.99 months will receive 3 mg 
• 
Patients =12 - 23.99 months will receive 3.5 mg 
• 
Patients ≥ 24 months will receive 4 mg.  
 
See Section 4.1.8 for injection instructions. See Section 5.0 for Dose Modifications based 
on Toxicities.  
 
Local control therapy may be administered during EUAs. See Section 4.1.6 for details.  
 
Following completion of each cycle, the next cycle starts on Day 29 if criteria to start next 
cycle have been met (see Section 4.1.2).  
 
Interventional Radiology Recording of First Injection 
Prior to the second injection, the central review of the interventional radiology 
recording taken after the first intra-arterial injection must be completed and sent for 
central review. Review comments will be communicated to the PI and CRA of the 
institution. This is important, as the review may affect dose modifications for the 
second and third injections (see Section 5.0). 
 
The therapy delivery map (TDMs) for all three cycles are on the next page.  
 
 

 
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4.2.1 
Intra-arterial Injection of Melphalan (All Cycles) 
This therapy delivery map covers all cycles and is on one (1) page. 
Each cycle lasts 28 days (21-30 days). Details of therapy are in 
Section 4.0. This therapy delivery map is to be used for each one 
of the 3 cycles. 
  
CIRCLE ONE:   RIGHT EYE  
LEFT EYE 
 
_________________________ 
 
________________ 
 
Patient COG ID number  
 
   DOB 
 
Begin therapy when ANC≥1000/µL, platelets ≥100,000/µL, Hemoglobin ≥8 g/dL, SGPT (ALT) < 2.5 x upper limit of normal (ULN) for age. 
DRUG 
ROUTE 
DOSAGE 
DAYS 
IMPORTANT NOTES 
OBSERVATIONS 
Melphalan 
 
Intra-arterial 
Age Based Dosing: 
= 6 - 11.99 months - 3 mg 
= 12 - 23.99 months - 3.5 mg 
≥ 24 months - 4 mg  
 
1 
 
a. History, Ht, Wt, BSA 
b. Performance Status 
c. Physical exam  
d. CBC (differential/platelets) 
e. Electrolytes (incl. Ca++, Po4, Mg++), 
creatinine, SGPT, bilirubin 
f. EUA with RETCAM images 
g. MRI of brain and orbits 
 
See Section 7.1 for details on follow-
up observations. 
 
OBTAIN OTHER STUDIES AS 
REQUIRED FOR GOOD 
PATIENT CARE 
 
Enter Cycle #: _____ 
 
Ht _________cm 
Wt _________kg 
BSA _________m2 
 
Date 
Due 
Date 
Given 
Day 
melphalan 
____mg 
Studies 
Comments (Include any held doses, or dose modifications) 
 
 
 
Enter calculated dose above and actual dose administered below 
 
 
1 
____mg 
(a,b,c,d,e)* g#, f%  
 
 
 
 
 
 
 
 
7 
 
c1,d,  
 
 
 
 
 
 
 
14 
 
c1,d,g2 
 
 
 
 
 
 
 
21-30 
 
b, c1,d, f2 
 
 
 
 
 
 
 
 
Local Control Therapy may be performed during EUAs. See Section 16.0 for details.  
Start next cycle when ANC≥1000/µL; platelets ≥100,000/µL; Hgb ≥8 g/dL.  
See Section 5.0 for Dose Modifications for Toxicities and the COG website posted materials for Supportive Care Guidelines. 
*Baseline observations must be performed ≤ 7 days prior to starting treatment 
# To be performed ≤ 14 days prior to enrollment only. 
%To be performed ≤ 14 days prior to enrollment and ≤ 7 days prior to each subsequent IA injection. Local Control Therapy may be performed during 
EUAs. 
1 Cycle 1 only  
2 Cycle 3 only. To be performed 14-28 days post 3rd IA melphalan injection.  
 

 
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5.0 
DOSE MODIFICATIONS FOR TOXICITIES 
5.1 
Dose of melphalan can be increased by 0.5 mg in case of large extraorbital branches 
of the ophthalmic artery (meningeal, ethmoid arteries) for the second and third cycle 
not to exceed the maximum allowed dose in Section 5.1.1. This increase in dose will 
be based on central review of the interventional radiology recording of the first 
injection. This central review will be performed within 14 days of receiving the data 
from the institution.  
 
5.1.1 
Age based minimum and maximum allowed doses:  
= 6 - 11.99 month: 
2.5 - 3.5 mg 
= 12 - 23.99 months: 
3.0 - 4.0 mg 
≥ 24 months: 
3.5 - 4.5 mg  
 
5.2 
The standard dose should be decreased by 0.5 mg if there are signs of poor tolerance 
of previous intra-arterial treatment, not to fall below the minimum allowed dose in 
Section 5.1.1. This includes any Grade 4 inflammation of the eyelids and conjunctiva 
(see grading scale below.) 
 
5.2.1 
Grading scale for inflammation of the eyelids and conjunctiva:  
 
Grade 1. Mild erythema of eyelids, orbit or forehead  
 
Grade 2. Erythema and swelling over eyelids, orbit or forehead  
 
Grade 3. Pain in the eye or orbit with erythema and/or swelling  
 
Grade 4. Swelling and/or pain lasting more than 7 days  
 
Patients who develop post-injection central artery occlusion that does not recanalize prior to the 
subsequent injection will be taken off protocol therapy. 
 
 
 

 
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6.0 
DRUG INFORMATION  
See the consent document for toxicities.  
6.1 
MELPHALAN - INTRA-ARTERIAL  
 
 
 
 
(08/28/13) 
(L-phenylalanine mustard, phenylalanine mustard, L-PAM, L-sarcolysin, Alkeran®) NSC #008806  
 
Source and Pharmacology:  
Melphalan, a phenylalanine derivative of nitrogen mustard, is a bifunctional alkylating agent. Melphalan 
forms covalent cross-links with DNA or DNA protein complexes thereby resulting in cytotoxic, mutagenic, 
and carcinogenic effects. The end result of the alkylation process results in the misreading of the DNA code 
and the inhibition of DNA, RNA, and protein synthesis in rapidly proliferating tumor cells. It is cell cycle 
non-specific. After IV administration, melphalan plasma concentrations decline rapidly in a bi-exponential 
manner with distribution phase and terminal elimination phase half-lives of approximately 10 and 
75 minutes, respectively. Plasma melphalan levels are highly variable after oral dosing, both with respect 
to the time of the first appearance of melphalan in plasma (range approximately 0 to 6 hours) and to the 
peak plasma concentration achieved. These results may be due to incomplete intestinal absorption, a 
variable "first pass" hepatic metabolism, or to rapid hydrolysis. The oral dose averages 61% ± 26% of that 
following IV administration. The terminal elimination plasma half-life of oral melphalan is 
1.5 ± 0.83 hours. The steady-state volume of distribution of melphalan is 0.5 L/kg. The extent of melphalan 
binding to plasma proteins ranges from 60-90%. Melphalan is eliminated from plasma primarily by 
chemical hydrolysis to monohydroxymelphalan and dihydroxymelphalan. The 24-hour urinary excretion 
of parent drug is approximately 10% suggesting that renal clearance is not a major route of elimination of 
parent drug. Penetration into CSF is low. Despite the fact that the contribution of renal elimination to 
melphalan clearance appears to be low, one pharmacokinetic study suggests dosage may need to be reduced 
in patients with renal impairment. 
 
Toxicity: 
Only limited data exist on the toxicity of intra-arterial melphalan. The anticipated toxicities for intra-arterial 
melphalan are listed in the first table. Toxicities of intravenous melphalan are provided in the second table 
for completeness. It is not known if these toxicities will occur in a patient receiving intra-arterial melphalan 
for retinoblastoma. 
 
The table below lists the anticipated toxicity profile of melphalan (intra-arterial for retinoblastoma): 
Incidence 
Toxicities 
Common 
(>20% of patients) 
Retinal vascular disorder, retinopathy, eye disorders – other: loss of vision, 
blurred vision, cataract, eye disorders – other: thinning or loss of eyelashes, eye 
disorders – other: periocular edema 
Occasional 
(5-20% of patients) 
Neutrophil count decreased, fever, bronchospasm 
Rare 
(<5% of patients) 
Injection site reaction, reproductive system and breast disorders – other: 
amenorrhea, azoospermia, reproductive system and breast disorders – other: 
sterility or male infertility, anaphylaxis, allergic reaction, pneumonitis, 
pulmonary fibrosis, treatment related secondary malignancy, febrile neutropenia 
Pregnancy 
& 
Lactation 
Pregnancy Category D  
Melphalan was embryolethal and teratogenic in rats following oral (6 to 
18 mg/m2/day for 10 days) and intraperitoneal (18 mg/m2) administration. 
Malformations resulting from melphalan included alterations of the brain 

 
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(underdevelopment, deformation, meningocele, and encephalocele) and eye 
(anophthalmia and microphthalmos), reduction of the mandible and tail, as well 
as hepatocele (exomphaly). It is unknown whether the drug is excreted in breast 
milk. 
 
The table below lists the toxicity profile of melphalan IV:  
Incidence 
Toxicities 
Common 
(>20% of patients) 
Endocrine disorders – other: syndrome of inappropriate antidiuretic hormone 
(SIADH), anemia, neutrophil count decreased, white blood cells decreased, 
platelet count decreased, alopecia, diarrhea, nausea, vomiting, mucositis oral 
Occasional 
(5-20% of patients) 
Reproductive system and breast disorders – other: amenorrhea, azoospermia, 
reproductive system and breast disorders – other: sterility or male infertility, 
injection 
site 
reaction, 
alanine 
aminotransferase 
increased, 
aspartate 
aminotransferase increased, blood bilirubin increased 
Rare 
(<5% of patients) 
Cardiac arrest, atrial fibrillation, vasculitis, rash maculo-papular, skin ulceration, 
seizures, anaphylaxis, allergic reaction, hepatobiliary disorders – other: hepatitis, 
hepatobiliary disorders – other: jaundice, hepatobiliary disorders – other: 
sinusoidal obstruction syndrome, blood and lymphatic system disorders, other:  
hemolytic anemia, pneumonitis, pulmonary fibrosis, treatment related secondary 
malignancy 
Pregnancy 
& 
Lactation 
Pregnancy Category D  
Melphalan was embryolethal and teratogenic in rats following oral (6 to 
18 mg/m2/day for 10 days) and intraperitoneal (18 mg/m2) administration. 
Malformations resulting from melphalan included alterations of the brain 
(underdevelopment, deformation, meningocele, and encephalocele) and eye 
(anophthalmia and microphthalmos), reduction of the mandible and tail, as well 
as hepatocele (exomphaly). It is unknown whether the drug is excreted in breast 
milk. 
 
Formulation and Stability:  
Melphalan for Injection is supplied as a sterile, nonpyrogenic, freeze-dried powder. Each single-use vial 
contains melphalan hydrochloride equivalent to 50 mg melphalan and 20 mg povidone. Melphalan for 
Injection is reconstituted using the sterile diluent provided. Each vial of sterile diluent contains sodium 
citrate 0.2 g, propylene glycol 6.0 mL, ethanol (96%) 0.52 mL, and SWFI to a total of 10 mL. Store at 
controlled room temperature 15°-30°C (59°-86°F) and protect from light.  
 
Intra-arterial Preparation: 
• 
Using appropriate aseptic technique, reconstitute to a concentration of 5 mg/mL by rapidly 
injecting 10 mL of the supplied diluent directly into the vial of lyophilized powder using a sterile 
needle (20-gauge or larger needle diameter) and syringe. Immediately shake vial vigorously until 
a clear solution is obtained. Rapid addition of the diluent followed by immediate vigorous shaking 
is important for proper dissolution.  
• 
Immediately dilute the dose to be administered in up to 20 mL of NS; the final volume of the 
product should be 20 mL. The concentration of the final drug product should be ≤ 0.45 mg/mL.  
• 
The final drug product should be filtered (e.g., with a 0.22 micron filter) prior to being dispensed.  
• 
A precipitate forms if the reconstituted solution is stored at 5°C. Do not refrigerate the reconstituted 
product. 

 
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(The time between reconstitution/dilution and administration of melphalan should be kept to a minimum 
because reconstituted and diluted solutions of melphalan are unstable. Over as short a time as 
30 minutes, a citrate derivative of melphalan has been detected in reconstituted material from the 
reaction of melphalan with the sterile diluent for melphalan. Upon further dilution with saline, nearly 
1% label strength of melphalan hydrolyzes every 10 minutes.)  
 
Guidelines for Administration: See Treatment (Section 4.0) and Dose Modifications (Section 5.0) sections 
of the protocol. 
 
Patients should receive oxymetazoline 0.05% (e.g., Afrin) two puffs into the nares on the side of the 
procedure—prior to the procedure to reduce blushing.  
 
The drug is then injected manually by repeated small bolus –pulsatile injection- at a rate of 1 mL/minute. 
The injection must be completed within 60 minutes of product reconstitution. 
 
Supplier: Commercially available. See package insert for further information.  
 
 
 
 

 
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7.0 
EVALUATIONS/MATERIAL AND DATA TO BE ACCESSIONED 
Timing of protocol therapy administration, response assessment studies, and surgical 
interventions are based on schedules derived from the experimental design or on established 
standards of care. Minor unavoidable departures (up to 72 hours) from protocol directed therapy 
and/or disease evaluations (and up to 1 week for surgery) for valid clinical, patient and family 
logistical, or facility, procedure and/or anesthesia scheduling issues are acceptable per COG 
administrative Policy 5.14 (except where explicitly prohibited within the protocol). 
 
7.1 
Required Clinical, Laboratory and Disease Evaluations  
All baseline studies must be performed prior to starting protocol therapy unless otherwise indicated 
below. Obtain other studies prior to start of phase unless otherwise indicated. 
 
STUDIES TO BE OBTAINED 
Baseline 
Cycle 1 
Subsequent 
Cycles 
End of 
Therapy 
During 
Follow-
up 
REQUIRED STUDIES 
 
History 
X 
X 
X 
X 
X3 
Physical Exam with VS 
X 
Weekly 
X 
X 
X3 
Ht, Wt, BSA 
X 
X 
X 
 
 
CBC, differential, platelets 
X 
Weekly 
Weekly 
X 
 
Performance Status 
X 
X 
X 
X 
 
Electrolytes including Ca++, PO4, 
Mg++ 
X 
X 
X 
X 
 
Creatinine, SGPT, bilirubin 
X 
X 
X 
X 
 
Interventional radiology recording 
 
X 
 
 
 
EUA# 
X 
X% 
X 
X 
 
MRI or CT of the brain and orbits 
with and without contrast 
X 
 
 
X6 
X4 
Visual Assessment Test 
 
 
 
 
X2 
OPTIONAL STUDIES 
 
Histopathology of enucleated eyes 
 
 
 
 
X1 
EUA 
 
 
 
 
X5 
 
# Please see 7.3 below for collection of required RETCAM images and Retinal Drawings with EUA. 
1 Enucleation (if required). See Section 13.2 for details. 
2To be administered once a year for 4 years, starting 1 year after completion of protocol therapy. Only for patients who receive 
all 3 courses of IA melphalan. See Section 13.1 for details.  
3To be performed every 3 months for the first year, every 4 months for the second year, and every six months for the third year  
4To be performed every 6 months for two years.  
5Recommended follow up EUA: every 6 weeks x2, followed by every 8 weeks x3 or more frequently as clinically indicated 
post protocol therapy.  
6 To be performed 14-28 days post 3rd IA melphalan injection. 
% Use diagnostic EUA prior to cycle 1. 
 
This table only includes evaluations necessary to answer the primary and secondary aims. 
Obtain other studies as indicated for good clinical care.  
 
 

 
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7.2 
Follow-up  
See COG Late Effects Guidelines for recommended post treatment follow-up:  
http://www.survivorshipguidelines.org/ 
 
Note: Follow-up data are expected to be submitted per the Case Report Forms (CRFs) 
schedule. 
 
7.3 
Collection of RetCam images, Retinal Drawings, Interventional Radiology 
Recording, and QA Documentation 
 
All central review should include: 
 
1. Retcam photo 
2. Retinal drawing 
3. Some statement about the presence and location of vitreous or subretinal seeds 
(preferred but not mandatory) 
 
Item #3 can be written on the retinal drawing 
 
 
7.3.1 
RetCam Images and Retinal Drawings 
RetCam images and retinal drawings from EUA’s are required to be submitted 
electronically to IROC Rhode Island (QARC) at the following time points: 
a. Diagnostic EUA (performed within 14 days prior to enrollment)-to be 
submitted within 7 days 
b. End of therapy (performed 14-28 days post injection #3) to be submitted 
within 35 days of 3rd injection. 
c. In the event of disease progression: RETCAM images and retinal drawings 
of the last 2 EUAs should be sent for central review within 7 days of the 
EUA showing disease progression. 
 
7.3.2 
Rapid Central Review 
Electronic copies of the RetCam images from each of the required time periods in 
Section 7.3.1 must be sent to IROC Rhode Island (QARC). DICOM files of these 
images are the preferred format. These files can be submitted via sFTP. 
Information for obtaining an sFTP account and submission instructions can be 
found at www.QARC.org. Follow the link labeled digital data. Alternatively, if 
sFTP is not feasible, the imaging may be burned to a CD and mailed to IROC 
Rhode Island (QARC). Sites using Dicommunicator may submit imaging via that 
application. Contact IROC Rhode Island (QARC) with questions or for additional 
information.  BMP files are discouraged but will be accepted if DICOM files are 
not available. The BMP files can be e-mailed to IROC Rhode Island (QARC) at 
DataSubmission@QARC.org or can be submitted via sFTP. The RetCam images 
taken at diagnostic EUA must be submitted to IROC Rhode Island (QARC) 
within 7 days of the procedure for a rapid review of eligibility. Central review 
of diagnostic EUA will be done prior to study entry to confirm International 
Classification System for Intraocular Retinoblastoma Group D. The 
ARET12P1 Diagnostic EUA Eligibility Review Transmittal form must be 
included with the RetCam images and retinal drawings. This form can be found on 

 
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the IROC Rhode Island (QARC) website, www.qarc.org. Central review for 
disease progression will occur within 2 weeks. If disease progression is confirmed 
by central review, the patient will be removed from protocol treatment and treated 
in a standard fashion at investigator discretion. 
 
7.3.3 
Required Submission of Interventional Radiology Recording of 1st IA injection 
Electronic copies of the interventional radiology recording from the first IA 
melphalan injection must be sent to IROC Rhode Island (QARC). DICOM files of 
these images are the preferred format. These files can be submitted via sFTP. 
Information for obtaining an sFTP account and submission instructions can be 
found at www.QARC.org. Follow the link labeled digital data. Alternatively, if 
sFTP is not feasible, the imaging may be burned to a CD and mailed to IROC 
Rhode Island (QARC) (see address below.) Sites using Dicommunicator may 
submit imaging via that application. Contact IROC Rhode Island (QARC) with 
questions or for additional information. BMP files are discouraged but will be 
accepted if DICOM files are not available. The BMP files can be e-mailed to IROC 
Rhode Island (QARC) at DataSubmission@QARC.org or can be submitted via 
sFTP. These file can also be submitted (via SFTP only) as common movie file 
types such as; .avi, .mpg, or .wmv. The interventional radiology recording taken 
during the first IA melphalan injection must be submitted to IROC Rhode 
Island (QARC) within 14 days of procedure. 
 
IROC Rhode Island (QARC)  
Building B, Suite 201 
640 George Washington Highway 
Lincoln, RI 02865-4207 
Phone: (401) 753-7600 
Fax: 
(401) 753-7601 
 
7.3.4 
Required Submission of Retinal Drawings 
Required Submission of Retinal Drawings Retinal drawings corresponding to each 
RetCam study should be submitted to IROC Rhode Island (QARC) when the 
RetCam images are submitted. The retinal drawings can be scanned and e-mailed 
to DataSubmission@QARC.org or can be submitted via sFTP. The treating 
ophthalmologist at each institution must submit a drawing of the eye based on the 
EUA from each of the required time periods in Section 7.3.1. The drawing may be 
done in whatever format is used at the local institution. Tumors should be 
numbered. Each tumor should be clearly labeled as abnormal without depending 
on color coding since form will be copied in black and white. This drawing will be 
utilized by the central reviewers to assist in confirmation of staging of the eye(s). 
The drawing should be labeled with the patient’s COG identification number and 
the study number (ARET12P1).  
 
 
8.0 
CRITERIA FOR REMOVAL FROM PROTOCOL THERAPY AND OFF STUDY 
CRITERIA 
8.1 
Criteria for Removal from Protocol Therapy 
 
a) Progressive disease - Unable to control disease  

 
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b) Any non-protocol chemotherapy or external beam radiation therapy is given 
c) Intraocular progression of disease is documented by the institutional assessment. Note: 
RETCAM images of the last 2 EUAs should be sent for central review  
within 7 
days of the EUA showing disease progression 
d) Positive disease found in the contralateral eye after receiving protocol treatment 
e) Occurrence of metastases 
f) Massive/Profound intra-vitreal hemorrhage 
g) Enucleation occurred prior to any Melphalan injection 
h) Refusal of further protocol therapy by patient/parent/guardian 
i) Completion of planned protocol therapy 
j) Physician determines it is in patient’s best interest 
k) Development of a second malignancy 
l) Repeat eligibility studies (if required) are outside the parameters required for eligibility 
m) Central artery occlusion after an injection which does not recanalize prior to the 
subsequent injection 
 
Patients who are off protocol therapy are to be followed until they meet the criteria for Off Study (see 
below). Follow-up data will be required unless patient is taken off study. 
 
8.2 
Off Study Criteria 
a) Death 
b) Lost to follow-up 
c) Patient enrollment onto another COG study with tumor therapeutic intent (eg, at 
recurrence) 
d) Withdrawal of consent for any further data submission. 
e) The fifth anniversary of the date the patient was enrolled on this study 
 
 
 

 
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9.0 
STATISTICAL CONSIDERATIONS 
9.1 
Sample Size and Duration 
A survey of potential enrollment at the 11 primary institutions participating in this trial indicates 
we can expect at least 24 patients per year will be enrolled with disease characteristics and organ 
function that meet the eligibility criteria for the protocol. Thirty-one (31) eligible and feasibility-
evaluable patients will be required in order to apply the statistical rules described below. 
Accounting for the possibility that 10% of patients will be either inevaluable or ineligible, we will 
enroll up to 34 patients. At the time of the amendment of the study design, 10 patients were enrolled; 
none were identified as inevaluable for the primary endpoint according to the definition in the 
amended protocol. We estimate enrollment can be concluded within 18 months of implementation 
of the modified design. Twelve months of accrual will be required and up to six months will be 
required to determine the feasibility status of all patients of patients enrolled in the first stage of the 
Study Design. 
 
9.2 
Study Design 
The primary goal of this trial is to determine the feasibility of delivering melphalan directly into 
the ophthalmic artery.  
 
Feasibility Outcome: Intra-arterial (IA) feasibility will be assessed over the 3 injections into the 
ophthalmic artery. A patient will be considered to have experienced IA therapy feasibility failure 
if: a) the interventional radiologist is not able to access the ophthalmic artery for chemotherapy 
administrations during the first three cycles of therapy; b) patient develops central retinal artery 
occlusion after the first or second cycle that does not reopen by the time the next injection is due; 
or c) the patient cannot receive all three treatments with IA therapy because of CTC AE 
complications Grade III or IV that are considered possibly, probably or likely related treatment.   
 
Evaluability for Feasibility Outcome: Any patient who does not experience IA feasibility failure 
event and is removed from protocol therapy prior to the third IA injection because: (1) the physician 
stops protocol therapy in the best interests of the patient; (2) the parent or guardian refuses further 
therapy; (3) disease is found in the contralateral eye; or (4) the patient does not qualify because 
repeat eligibility studies are outside enrollment requirements will be considered inevaluable for the 
primary outcome measure and replaced for evaluation of the primary goal. All other patients will 
be considered evaluable for the primary endpoint. Each patient will require, at most, 4 months to 
complete the feasibility evaluation. Any feasibility evaluable patient who does not experience 
feasibility failure will be considered a feasibility success. 
 
Design for the Primary Outcome Measure: Feasibility will be evaluated using a two-stage design. 
 
Cumulative Number of 
Feasibility Successes 
Decision 
Stage 1: Enter 12 feasibility 
evaluable patients 
8 or fewer 
Terminate the trial because the 
therapy is considered not feasible 
to deliver. 
 
9 or more 
Proceed to Stage 2. 
Stage 2: Enter 19 additional 
feasibility evaluable 
patients  
25 or fewer 
Terminate the trial with the 
conclusion the therapy is 
considered not feasible to deliver. 
 
26 or more 
Terminate the trial because the 
therapy is considered feasible to 
deliver. 

 
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If the true feasibility failure rate is 28%, the regimen will be identified as not feasible to deliver with 
probability 91%. If the true feasibility failure rate is 10%, the regimen will be identified as feasible to 
deliver with probability 90%. 
 
Assessment of Ocular Salvage 
Ocular Salvage: Ocular salvage will be assessed over the 2 years following start of protocol therapy. A 
patient will be considered an ocular-salvage success if enucleation because of disease progression or 
toxicity is not required during the 2 years following enrollment onto ARET12P1. Any patient who is lost 
to follow-up or for whom follow-up is terminated electively prior to 2 years by patient or parent preference 
will be considered inevaluable for the ocular salvage endpoint.  
 
The primary analytic endpoint of this trial will be feasibility of delivery of IA therapy. The accrual target 
for this study will not be adjusted for the number of patients considered not evaluable for the ocular salvage 
endpoint. 
Design for Ocular Salvage Assessment: Interim assessment of this aim will not be done since the salvage 
endpoint could require 2 years of follow-up after enrollment to ascertain. 
The probability of ocular salvage will be assessed after 31 feasibility -evaluable patients have been enrolled. 
If 11 or fewer patients have ocular salvage (observed salvage rate 32%), we will consider the therapy to 
have an insufficient ocular salvage probability; otherwise, the data will be considered of sufficient interest 
Probability of Acceptance
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Response Probability
0.70
0.72
0.74
0.76
0.78
0.80
0.82
0.84
0.86
0.88
0.90
0.92
0.94
0.96
Power Characteristics
Design
Revised Design

 
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with respect to ocular salvage for further investigation. If the true probability of ocular salvage is 0. 50, the 
therapy will be considered of sufficient interest for further study with probability 93%. If the true probability 
of ocular salvage is 0.25, the therapy will be considered not of sufficient interest for further study with 
probability 94%. If, at any time, 21 or more patients experience ocular salvage failure, enrollment will be 
suspended with the conclusion the therapy does not have a sufficient salvage rate for further consideration.  
If fewer or greater than 31 patients are evaluable for the ocular salvage endpoint, the cutoff for the number 
of patients who have ocular salvage success will be adjusted to preserve the probability of identifying the 
therapy as not of sufficient interest for further examination to be at least 90% when the true probability of 
ocular salvage is only 25%. Examples of such adjustments are provided in the following table. 
 
Number of Patients 
Evaluable for Ocular 
Salvage 
Number of Ocular 
Patients with Ocular 
Salvage Success  That 
Implies the Therapy is 
not of Interest for 
Further Investigation 
Probability The 
Therapy is Considered 
Not of Interest if The 
True Ocular Salvage 
Rate is 25% 
Probability The 
Therapy is Considered 
of Interest if The True 
Ocular Salvage Rate is 
45% 
34 
12 or fewer 
0.94 
0.94 
28 
10 or fewer 
0.93 
0.91 
26 
9 or fewer 
0.91 
0.92 
 
Assessment of the Need for Systemic Chemotherapy 
 
Systemic Chemotherapy Administration: The need to administer systemic chemotherapy because of 
progressive disease in the eye considered for IA melphalan feasibility will be assessed over the 2 years 
following start of protocol therapy. A patient will be considered as requiring systemic chemotherapy if 
systemic cytotoxic chemotherapy of any kind is required because of disease progression in the affected eye 
at any time during the 2 years following enrollment onto ARET12P1. Any patient who is lost to follow-up 
or for whom follow-up is terminated electively prior to 2 years by patient or parent preference will be 
considered inevaluable for the evaluation of the need for systemic chemotherapy to control progressive 
disease in the affected eye. 
Design for Assessing the Need for Systemic Chemotherapy: Interim assessment of this aim will not be done 
since the salvage endpoint could require 2 years of follow-up after enrollment to ascertain. 
The probability of the need for systemic chemotherapy will be assessed after 31 systemic chemotherapy-
evaluable patients have been enrolled. If all 31 such patients are evaluable for ocular salvage, the following 
design will be employed. If 19 or more patients require systemic chemotherapy (observed frequency 61%), 
we will consider the therapy to have an insufficient freedom from systemic chemotherapy probability; 
otherwise, the data will be considered of sufficient interest with respect to freedom from systemic 
chemotherapy for further investigation. If the true probability of freedom from chemotherapy is 0.50, the 
therapy will be considered of sufficient interest with respect to this endpoint with probability 93%. If the 
true probability of the need for systemic chemotherapy is 0.75, the therapy will be considered not of 
sufficient interest for this endpoint with probability 94%. If, at any time, 19 require chemotherapy to control 
progressive disease in the affected eye, enrollment will be suspended with the conclusion the therapy does 
not meet the criteria for a treatment sufficient interest for this endpoint.  
If fewer or greater than 31 patients are evaluable for the need for chemotherapy endpoint, the cutoff for the 
number of patients who require systemic chemotherapy will be adjusted to preserve the probability of 
identifying the therapy as not of sufficient interest for further examination to be at least 90% when the true 

 
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Page 35 
probability of the need for chemotherapy is at least 75%. Examples of such adjustments are provided in the 
following table. 
 
Number of Patients 
Evaluable for Ocular 
Salvage 
Number of Ocular 
Patients that do not 
Require Systemic 
Chemotherapy 
Probability The 
Therapy is Considered 
Not of Interest if The 
True Probability of 
Requiring 
Chemotherapy is 75% 
Probability The 
Therapy is Considered 
of Interest if The True 
Probability of 
Requiring Systemic 
Chemotherapy is 50% 
34 
12 or fewer 
0.94 
0.94 
28 
10 or fewer 
0.93 
0.91 
26 
9 or fewer 
0.91 
0.92 
 
Assessment of Rate of Metastases of Retinoblastoma 
Metastatic Disease Failure: Patients will be considered for the evaluation of metastatic disease provided 
the individual receives at least 1 dose of IA therapy and is followed until the patient experiences disease 
progression or relapse, is diagnosed with a second malignant neoplasm, dies or completes two years of 
follow-up without any of the aforementioned events occurring, whichever occurs first. The new finding of 
extraocular disease after the initiation of protocol therapy will be considered metastatic disease failure. 
Appearance of intraocular tumor in the other eye either during or after protocol therapy will not be 
considered metastatic disease. Appearance of an isolated pineal tumor during therapy and follow up will 
not be considered as metastatic recurrence especially in the context of a young patient with a genetic 
predisposition to developing bilateral/trilateral retinoblastoma.     
 
Design for Assessing Rate of Metastatic Disease Incidence: The primary analytic endpoint of this trial will 
be feasibility of delivery of IA therapy. The accrual target for this study will not be adjusted for the number 
of patients considered not evaluable for the metastatic disease endpoint. 
The probability of metastatic disease will be assessed after 31 feasibility-evaluable patients have been 
enrolled. If all 31 such patients are evaluable for metastatic disease incidence, the following design will be 
employed. If 1 or fewer patients experience metastatic disease, (observed rate of metastatic disease 
incidence: 3.2%), we will consider the therapy to have a sufficiently low rate of metastatic disease to be 
considered for further evaluation; otherwise, the data will be considered indicative of an excessive rate of 
metastatic disease. If the true rate of metastases is 0.10, the therapy will be considered of to have an 
excessive rate of metastases probability 83%. If the true rate of metastases is 0.03, the therapy will be 
considered have a sufficiently low rate of metastases with probability 76%. If, at any time, 2 or more 
patients experience metastatic disease as defined above, the COG DSMC will be notified and CTEP 
consulted regarding the next steps to take with respect to the protocol.  
Because of the definition of evaluability for feasibility, the number of patients evaluable for the occurrence 
of metastatic disease may differ from 31. In such cases the cutoff for the number of patients who are 
diagnosed with metastatic disease as defined above with be adjusted to preserve the probability of 
identifying the therapy as having an excessive metastatic disease probability to be at least 80% when the 
true probability of metastatic disease is 10%. Examples of such adjustments are provided in the following 
table. 
 
 

 
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Number of Patients 
Evaluable for 
Metastatic Disease 
Number of Ocular 
Patients with Metastatic 
Disease That Implies 
the Therapy is May not 
be of Interest for 
Further Investigation 
Probability The 
Therapy is Considered 
Not of Interest if The 
True Metastatic 
Disease Rate is 10% 
Probability The 
Therapy is Considered 
of Interest if The True 
Metastatic Disease Rate 
is 3% 
34 
2 
0.87 
0.73 
28 
1 
0.95 
0.43 
 
Evaluation of the toxicities and adverse events associated with delivering multiple doses of intra-arterial 
chemotherapy: The occurrence of each Grade 3 or higher CTC AE adverse experience will be recorded in 
each patient-cycle. The percentage of patients with each toxicity will be tabulated per cycle according to 
the methodology in place for the study progress report at the time. 
 
The study will be temporarily suspended for evaluation if there is any episode of stroke or death and the 
study will be terminated if it is determined that the IA procedure was a significant cause. 
 
Evaluation of vision outcomes in children treated with intra-arterial chemotherapy: All patients who retain 
the affected eye 1 year after completion of therapy will be evaluated for visual acuity according to the 
Amblyopia Treatment Study Visual Acuity Testing Protocol. The mean visual acuity that will be obtained 
1 year after protocol therapy will be estimated by the average visual acuity amongst patients evaluated19 
the expected width of the 95% confidence interval for the visual acuity score (logMAR) is presented below 
as a function of the number of patients who are evaluated at the one-year-post-treatment endpoint. The 
expected standard error of logMAR is reported to be 0.064 
 
Number of Patients Evaluated 
Expected Width of the 95% Confidence Interval 
10 
0.040 
30 
0.023 
 
Evaluation of the effects of intra-arterial therapy on the histopathology of eyes enucleated for progression: 
The monitoring rule for ocular salvage will limit the number of eyes available for evaluation. We project a 
maximum of 25 eyes will be available for evaluation. As noted in Section 2.0, various characteristics such 
as viable vitreous seeds and invasion into the optic nerve were observed. In previous examinations there 
has also been evidence of ischemic atrophy involving the outer retina and choroid as well as extensive 
choroidal and outer retinal atrophy. The proportion of enucleated eyes with each of these various 
characteristics will be calculated, as well as the 95% confidence intervals. The expected size of the 
confidence intervals, as a function of the number of eyes available and relative frequency of the particular 
characteristic. 
 
Number of Eyes Examined 
True Proportion with the Particular 
Histopathological Characteristic 
Expected 95% Confidence 
Interval 
10 
0.1 
0.011-0.42 
10 
0.25 
0.058-0.59 
10 
0.5 
0.20-0.80 
25 
0.1 
0.023-0.28 
25 
0.25 
0.10-0.46 
25 
0.5 
0.30-0.70 
 

 
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Monitoring for complications of catheter insertion:  
The analytic unit for this outcome is the patient-catheter insertion. Each time a catheter insertion procedure 
is performed, the patient will be monitored for the subsequent 48 hours for the occurrence of any of the 
following complications: (1) thrombosis of the femoral artery; (2) dissection of any artery; (3) hematoma 
at the site of insertion of 3 centimeters or more in diameter; (4) emboli cerebral; or (5) any embolus in the 
lower extremity that results in vascular insufficiency. If any of these 5 events a catheter event will be 
considered to have occurred. Otherwise, the patient will be considered free of catheter events for that 
particular insertion. 
 
A Bayesian monitoring rule will be used to assess the consistency of the data with a catheter event rate that 
does not exceed 20% with high probability. Each analytic unit will be considered independent of all other 
analytic units. A beta prior with α=0.2 and β=0.8 to represent that the maximum complication rate 
considered acceptable as 20% with a substantial standard deviation to quantify the uncertainty regarding 
the complication rate. At each review of the study data where 10 or more patient-catheter insertion instance 
have occurred, the posterior probability of an excessive complication rate will be calculated as: 
(
)
(
)
( )
(
) (
)
(
)
(
)
( )
(
) (
)
(
)
0.2
0.8
1
0.20
1
0.2
0.8
0
1
1
1
0.2
0.8
Pr
0.20 |
1
1
1
0.2
0.8
n x
x
Excessive Complication Rate
n x
x
n p
p
p
p
x
p
Data
dp
n u
u
u
u
du
x
−
−
−
−
−
−
Γ

−
−

Γ
Γ

>
=
Γ

−
−

Γ
Γ

∫
∫
  
Where n is the number of patient-catheter insertions and x is the number of those analytic units during 
which a catheter event is observed. If this probability exceeds 80%, we will identify the regimen to the 
relevant COG DSMC, the rare tumor leadership and CTEP as associated with catheter event rate that is 
excessive. Examples of situations in which the rule will indicate excessive toxicity are presented below. 
 
Number of Patient-Catheter 
Insertion Instances 
Number of Analytic Units 
Where a Catheter Event 
Occurs 
(
)
Pr
0.20 |
Excessive Complication Rate
p
Data
>
 
10 
4 
0.90 
15 
5 
0.86 
20 
6 
0.83 
25 
7 
0.81 
 
 
 

 
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9.3 
Gender and Minority Accrual Estimates  
The gender and minority distribution of the study population is expected to be: 
Accrual Targets 
Ethnic Category 
Sex/Gender 
Females 
 
Males 
 
Total 
Hispanic or Latino 
7 
+ 
5 
= 
12 
Not Hispanic or Latino 
9 
+ 
13 
= 
22 
Ethnic Category: Total of all subjects 
16 
 
(A1) 
+ 
18 
 
(B1) 
= 
34 
 
(C1) 
Racial Category 
 
American Indian or Alaskan Native 
0 
+ 
0 
= 
0 
Asian 
0 
+ 
4 
= 
4 
Black or African American 
7 
+ 
6 
= 
13 
Native Hawaiian or other Pacific Islander 
0 
+ 
0 
= 
0 
White 
9 
+ 
8 
= 
17 
Racial Category: Total of all subjects 
16 
 
(A2) 
+ 
18 
 
(B2) 
= 
34 
 
(C2) 
 
 
10.0 
EVALUATION CRITERIA 
10.1 
Common Terminology Criteria for Adverse Events (CTCAE) 
This study will utilize the CTCAE of the National Cancer Institute (NCI) for toxicity 
and performance reporting. The descriptions and grading scales found in the revised 
CTCAE version 4.0 will be utilized for reporting beginning October 1st, 2010. All 
appropriate treatment areas should have access to a copy of the CTCAE version 4.0, 
which can be downloaded from the CTEP web site (http://ctep.cancer.gov). 
10.2 
Response Criteria 
There are no established response criteria for retinoblastoma that describe the response of 
the entire eye inclusive of all retinal lesions and vitreous disease. The response criteria 
defined below will NOT be used as study endpoints, but will be used to gather preliminary 
information on overall response and patterns of failure of eyes treated on this protocol 
therapy that may be useful in designing response criteria for future protocols. RetCam 
images will be submitted centrally to correlate with reported response from treating site. 
The study endpoint will be defined only by Section 10.3 Definition of Disease Progression 
for an individual eye. 
 
10.2.1 Type I or IV Response 
Complete Type I regression pattern with calcification or Type IV with flat 
chorioretinal scars, or avascular, linear, white gliosis regression of all retinal 
tumors documented by at least two EUA’s minimum of three weeks apart. No 
evidence of active vitreous tumor. No evidence of new lesions. Complete response 
is dated from the time all lesions have complete regression. 

 
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10.2.2 Type II or III Response 
Reduction in size with Type II or III regression pattern in some lesions (i.e. not all 
lesions have Type I and/or Type IV regression pattern). No evidence of active 
vitreous tumor. Partial response is dated from the time of first observation. In 
addition, there can be no appearance of new lesions or progression of any lesion. 
 
10.2.3 Stable Disease (SD) 
No change in size/regression of retinal tumors and/or persistence of any active 
vitreous tumor. No evidence of new lesions. 
 
10.2.4 Local Recurrence 
Tumor regrowth at prior sites and/or new sites of retinal tumors that can be 
controlled by local therapy and/or plaque. 
 
10.2.5 Retinal Recurrence 
Tumor regrowth at prior sites and/or new sites of retinal tumors that canNOT be 
controlled by local therapy and/or plaque. 
 
10.2.6 Subretinal Recurrence 
Tumor regrowth involving expansion of new onset of subretinal seeding. 
 
10.2.7 Vitreal Recurrence 
Tumor regrowth involving expansion or new onset of vitreous seeding. 
 
10.2.8 Extraocular Recurrence 
Tumor regrowth involving optic nerve, and/or orbit. 
 
10.2.9 Metastatic Systemic Recurrence 
Tumor metastases to bone, bone marrow, lymph node, brain and/or other distant 
organ outside eye. 
 
10.3 
Definition of Disease Progression for an Individual Eye 
Any tumor regrowth requiring enucleation and/or external beam radiation, and/or further 
chemotherapy beyond that given per protocol. At the time of disease progression, the 
pattern of recurrence will be specified using the Response Criteria (10.2.4-10.2.9) by 
choosing all sites of recurrence that apply. Any extraocular recurrence and/or metastatic 
systemic recurrence will be considered disease progression and the patient will be 
considered treatment failure. 
 
 
 

 
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11.0 
ADVERSE EVENT REPORTING REQUIREMENTS  
11.1 
Purpose 
Adverse event data collection and reporting, which are required as part of every clinical 
trial, are done to ensure the safety of patients enrolled in the studies as well as those who 
will enroll in future studies using similar agents.  
 
11.2 
Determination of Reporting Requirements 
Reporting requirements may include the following considerations: 1) the characteristics of 
the adverse event including the grade (severity); 2) the relationship to the study therapy 
(attribution); and 3) the prior experience (expectedness) of the adverse event. 
  
Commercial agents are those agents not provided under an IND but obtained instead from 
a commercial source. In some cases an agent obtained commercially may be used for 
indications not included in the package label. In addition, NCI may on some occasions 
distribute commercial supplies for a trial. Even in these cases, the agent is still considered 
to be a commercial agent and the procedures described below should be followed. 
 
Determine the prior experience Expected events are those that have been previously 
identified as resulting from administration of the agent. An adverse event is considered 
unexpected, for reporting purposes only, when either the type of event or the severity of 
the event is not listed in:  
• 
The current known toxicities for each commercial agent as provided in the 
Drug Information for Commercial Agents Used by the Children’s Oncology 
Group posted on the COG website; or 
• 
The drug package insert 
 
 Secondary Malignancy 
A secondary malignancy is a cancer caused by treatment for a previous malignancy (eg, 
treatment with investigational agent/intervention, radiation or chemotherapy). A metastasis 
of the initial neoplasm is not considered a secondary malignancy.  
 
All secondary malignancies that occur following treatment need to be reported via CTEP-
AERS. Three options are available to describe the event:  
• 
Leukemia secondary to oncology chemotherapy.  
• 
Myelodysplastic syndrome  
• 
Treatment related secondary malignancy 
 
11.3 
Reporting of Adverse Events for Commercial Agents - CTEP-AERS abbreviated 
pathway 
 
Commercial reporting requirements are provided in Table B. The commercial agent(s) used 
in this study are listed in the front of this protocol immediately following the Study 
Committee roster.  
 
• COG requires the CTEP-AERS report to be submitted within 7 calendar days of 
learning of the event.  
• Use the NCI protocol number and the protocol-specific patient ID provided 

 
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during trial registration on all reports. 
 
CTCAE term (AE description) and grade:  The descriptions and grading scales found 
in the NCI Common Terminology Criteria for Adverse Events (CTCAE) version 4.0 will 
be utilized for AE reporting and are located on the CTEP website at:  
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  All 
appropriate treatment areas should have access to a copy of the CTCAE. 
 
Table B  
Reporting requirements for adverse events experienced by patients on study who 
have NOT received any doses of an investigational agent on this study. 
 
CTEP-AERS Reporting Requirements for Adverse Events That Occur During 
Therapy With a Commercial Agent or Within 30 Days1 
Attribution 
Grade 4 
Grade 5 
 
Unexpected 
Expected 
 
Unrelated 
or 
Unlikely 
 
 
CTEP-AERS 
Possible, 
Probable, 
Definite 
CTEP-AERS 
 
CTEP-AERS 
1This includes all deaths within 30 days of the last dose of treatment with a 
commercial agent, regardless of attribution. Any death that occurs more than 
30 days after the last dose of treatment with a commercial agent which can 
be attributed (possibly, probably, or definitely) to the agent and is not due to 
cancer recurrence must be reported via CTEP-AERS. 
 
11.4 
Routine Adverse Event Reporting 
Note: The guidelines below are for routine reporting of study specific adverse events on 
the COG case report forms and do not affect the requirements for CTEP-AERS reporting. 
 
The NCI defines both routine and expedited AE reporting.  Routine reporting is 
accomplished via the Adverse Event (AE) Case Report Form (CRF) within the study 
database.  For this study, routine reporting will include all toxicities reported via CTEP-
AERS and all Grade 3 and higher Adverse Events.  
 
 
12.0 
STUDY REPORTING AND MONITORING  
The Case Report Forms and the submission schedule are posted on the COG web site with each 
protocol under “Data Collection/Specimens”. A submission schedule is included. 
 
12.1 
CDUS 
This study will be monitored by the Clinical Data Update System (CDUS). Cumulative 
CDUS data will be submitted quarterly to CTEP by electronic means. Reports are due 
January 31, April 30, July 31 and October 31. This is not a responsibility of institutions 
participating in this trial. 
 

 
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12.2 
Data and Safety Monitoring Committee 
To protect the interests of patients and the scientific integrity for all clinical trial research 
by the Children’s Oncology Group, the COG Data and Safety Monitoring Committee 
(DSMC) reviews reports of interim analyses of study toxicity and outcomes prepared by 
the study statistician, in conjunction with the study chair’s report. The DSMC may 
recommend the study be modified or terminated based on these analyses.  
 
Toxicity monitoring is also the responsibility of the study committee and any unexpected 
frequency of serious events on the trial is to be brought to the attention of the DSMC. The 
study statistician is responsible for the monitoring of the interim results and is expected to 
request DSMC review of any protocol issues s/he feels require special review. Any COG 
member may bring specific study concerns to the attention of the DSMC.  
 
The DSMC approves major study modifications proposed by the study committee prior to 
implementation (e.g., termination, dropping an arm based on toxicity results or other trials 
reported, increasing target sample size, etc.). The DSMC determines whether and to whom 
outcome results may be released prior to the release of study results at the time specified 
in the protocol document. 
 
 
13.0 
SPECIAL STUDIES SPECIMEN REQUIREMENTS 
13.1 
Visual Assessment Study 
This study will test the visual acuity of the affected eye using a single surround HOTV, also known 
as the amblyopia treatment study visual acuity protocol. The test will be performed by either an 
ophthalmologist or their appropriately trained designate – an optometrist, ophthalmic technician 
or orthoptist. 
 
This study is required for all patients who complete all three courses of IA melphalan treatment 
and retain the affected eye one year after the completion of therapy. Most children on this study 
will be between 3-5 years of age 
 
On this study visual acuity will be tested once a year for 4 years, starting 1 year after completion 
of protocol therapy.  
 
13.2 
Histopathology of Eyes Enucleated for Disease Progression 
This optional study is open to patients who are removed from protocol therapy due to disease 
progression or due to parent’s request or physician recommendation and subsequently undergo 
enucleation. This study is designed carefully to assess eyes enucleated due to retinoblastoma for 
the presence certain histopathologic features that are known or suspected to affect prognosis 
adversely and to evaluate the changes associated to intra-arterial chemotherapy. See Appendix II 
for tissue handling guidelines.  
 
13.2.1 Summary of Tissue Segments to be Submitted 
• 1-2 H&E stained slides: Main A-P P-O segment 
• P-O Sections containing complete optic nerve head are mandatory – at least 1 good 
representative level is recommended; if possible 2 levels are preferred.  
• 2 H&E stained slides: Segments of breadloafed calottes (2 cassettes)  

 
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• 1 H&E stained slides: Transverse section of optic nerve from region of true surgical margin 
(remove and place in separate container of fixative prior to harvesting fresh tumor tissue).  
• 1 set of unstained slides of same cassettes as H&E stained slides submitted 
 
13.2.2 Labeling 
All slides must be labeled with the study number (ARET12P1), the patient’s COG patient I.D. 
number, the patient’s surgical pathology number, block number and the collection date.  
 
Data should be recorded on the Specimen Transmittal Form. A print out of this form along with the 
institutional pathology report with the patient’s name removed must accompany the sample(s).  
 
13.2.3 Specimen Shipping 
 
For courier account information, please refer to the courier account usage guidelines found at: 
https://members.childrensoncologygroup.org/prot/biology.asp 
 
Slides, pathology reports and transmittal forms should be sent to the Biopathology Center.  
 
COG Biopathology Center – ARET12P1 
Nationwide Children’s Hospital 
700 Children’s Drive, WA1340** 
Columbus, OH 43205 
Phone: 614-722-2865 
Fax: 614-722-2897 
 
**Be sure to include the room number. Packages received without the room number may be 
returned to the sender. 
 
 

 
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14.0 
IMAGING STUDIES REQUIRED AND GUIDELINES FOR OBTAINING  
Timing of protocol therapy administration, response assessment studies, and surgical 
interventions are based on schedules derived from the experimental design or on established 
standards of care. Minor unavoidable departures (up to 72 hours) from protocol directed therapy 
and/or disease evaluations (and up to 1 week for surgery) for valid clinical, patient and family 
logistical, or facility, procedure and/or anesthesia scheduling issues are acceptable per COG 
administrative Policy 5.14 (except where explicitly prohibited within the protocol). 
14.1 
Imaging Guidelines 
CT and MRI guidelines are available on the COG Member site at: 
https://members.childrensoncologygroup.org/_files/reference/RefMaterial/DiagnosticIma
gingGuidelines_MRI&CT.pdf. 
 
See also Section 10 for overview of response assessment and preferred imaging studies.  
 
Patients should have the traditional imaging/staging studies performed at their treating 
hospital for diagnosis (see Table 7.1.1).  
 
MRI with and without gadolinium of head and orbits is required 2 weeks prior to study 
entry, at end of protocol therapy and every 6 months for 2 years during follow-up for all 
patients. If MRI is not available, CT with and without contrast may be substituted.   
 
MRI may have advantages over CT, especially for intraocular disease, and is thus 
recommended, but not required. It should not be used in place of ophthalmologic exams. 
If MRI is used, it is recommended that both post- gadolinium T1-weighted images be 
obtained for surveillance of intracranial disease, including trilateral retinoblastoma and 
orbital T2-weighted MRI of the eye with fast spin echo (FSE) and surface coils (thin section 
3-D FSE T2-weighted sequence) be obtained for surveillance of intraocular disease.4,6,20  
 
Head MRI’s (or CT) done at study entry and for surveillance are NOT required to be 
submitted for central review. There will be central review of RetCam images and imaging 
studies that are required for the evaluation of the radiation therapy. 
 
 
 

 
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15.0 
GUIDELINES FOR RADIOACTIVE PLAQUE TREATMENT 
Timing of protocol therapy administration, response assessment studies, and surgical 
interventions are based on schedules derived from the experimental design or on established 
standards of care. Minor unavoidable departures (up to 72 hours) from protocol directed therapy 
and/or disease evaluations (and up to 1 week for surgery) for valid clinical, patient and family 
logistical, or facility, procedure and/or anesthesia scheduling issues are acceptable per COG 
administrative Policy 5.14 (except where explicitly prohibited within the protocol). 
 
Radiation therapy (RT) for patients on COG protocols can only be delivered at approved 
COG RT facilities (per COG administrative policy 3.9).  
 
No external beam radiation therapy including intensity modulated radiotherapy (IMRT), 
stereotactic radiotherapy, stereotactic radiosurgery, or proton beam therapy is permitted on this 
protocol. Plaque brachytherapy is the only radiotherapy permitted by protocol.  
 
For eyes that fail protocol therapy by definitions in Section 10.3, the further therapy will be 
determined at the discretion of the treating physician and will not be mandated by this protocol.  
15.1 
Timing 
There must be at least 6 weeks between the last local ophthalmic therapy (any included in 
Section 16) or systemic chemotherapy (whichever was later) and the start of plaque 
radiotherapy 
15.2 
Isotope  
Iodine-125 or Ruthenium-106 can be utilized for plaques. 
15.3 
Plaque Size 
The plaque size is chosen so that the tumor base is covered entirely by the plaque with a 
tumor free margin of at least 1 – 2 mm on all sides. (For example, a tumor with a basal 
diameter of 10 mm would be plaqued with a plaque of at least 12-14 mm in diameter.)  
An exception is permissible if the tumor is < 2 mm of the optic nerve. In this case, the 
plaque may be trimmed (or “notched”) around the optic nerve so that the posterior edge of 
the plaque lies between the optic nerve and the posterior edge of the tumor.  
15.4 
Radiation Dose 
The tumor dose is prescribed at the apex of the tumor. The dose rate at the prescription 
point must be > 0.4 Gy/h but < 0.8 Gy/h. 
 
Three dimensional (3D) treatment planning is encouraged. International Commision on 
Radiation Units and Measurements (ICRU) Reports 50, 62, and 72 (www.icru.org) define 
prescription methods and nomenclature that will be utilized for this study. Imaging studies 
for this protocol must have slice thicknesses of 1 mm or less. Treatment planning will be 
based on the following definitions: 
 
Gross target volume (GTV) is the volume of disease seen on planning imaging studies. 
 
Clinical target volume (CTV) is equal to the GTV  
 
Planning target volume (PTV) is equal to CTV. 

 
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If two dimensional (2D) treatment planning is employed, the thickness of the tumor is 
defined as the distance from the interior surface of the sclera to the apex of the tumor. The 
sclera is assumed to be 1 mm thick.  Thus, if a tumor is said to be 3 mm thick, the point of 
dose prescription is 4 mm from the surface of the radioactive plaque, i.e. 3 mm thick tumor 
+ 1 mm thick sclera = 4 mm. If the plaque is placed over one of the ocular muscles, the 
plaque must be considered to be 1 mm away from the external surface of the sclera, i.e. 3 
mm thick tumor + 1 mm thick sclera + 1 mm muscle thickness = 5 mm. If overlying 
vitreous seeds are present, the dose is designed to include those seeds. 
 
The prescription dose to the tumor apex is 36 Gy and will serve as the prescription 
dose for this protocol for both 2D and 3D treatment planning.  
 
This dose, with allowance for minor deviations of up to 10% or up to 39.6 Gy, has 
supportive data for safety in salvaged eyes in multiple series.21,22  
 
15.5 
Normal tissue dosimetry 
The organs at risk guidelines in this section are recommendations. If the recommended 
doses to the organs at risk are exceeded because of target volume coverage requirements 
or other conditions, and explanation should be included in the quality assurance 
documentation.  
 
Table 15.5: Organs at risk (OAR) and Planning organ at risk (PRV) dose guidelines for 3D 
treatment planning 
Organ 
Volume (%) 
Dose (Gy) 
Lens 
100% 
18 Gy 
Optic Nerve 
100% 
54 Gy 
Lacrimal Gland 
100% 
30 Gy 
 
15.5.1 For 3D treatment planning the following defines required normal tissue DVH data: 
 
Sclera  
Defined as a 1 mm thick shell making up the radiographic “edge” of the eye. For 
the purposes of this study the cornea will be included in this volume for simplicity. 
No scleral necrosis was seen in the salvage series from C. L. Shields, et al. with 
tumor base dose of 120 Gy and maximal tumor base dose of 358 Gy with 5-year 
follow-up.21,22 
 
Optic nerve  
The optic nerve will generally be shielded by the lip of the plaque and exposure 
minimized by careful plaque positioning. 
 
Lacrimal Gland 
 
Lens 
 

 
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15.5.2 For 2D treatment planning the following define required  
Sclera 
The dose to the sclera is estimated and reported at a point on the central axis of the 
plaque 1 mm from the surface of the plaque. This point is approximately coincident 
with the internal surface of the sclera near the center of the tumor. 
 
Optic nerve  
The dose to the center of the optic disc is calculated and reported.  
 
Contralateral Retina (same eye) 
The dose to the retina opposite the tumor is calculated and reported. The dose is 
calculated 16 mm from the scleral surface at the base of the tumor measured along 
a diameter of the globe passing through the apex of the tumor for infants ≤ 6 
months of age and 20 mm for patients > 6 months of age. 
 
Lens 
The dose to the center of the lens is calculated and reported. 
 
15.6 
QA Documentation 
No on-treatment review will be required for this protocol. It is recognized that the dose 
distribution from brachytherapy implants is inherently non-uniform. 
 
15.6.1 Institutions are required to submit the treatment plan in digital format. 
Submission of treatment plans in digital format (either DICOM RT or RTOG 
format) is required. Digital data must include CT scans, structures, plan, and dose 
files. Submission may be by either sFTP or CD. Instructions for data submission 
are on the IROC Rhode Island (QARC) web site at www.qarc.org under "Digital 
Data." Any items on the list below that are not part of the digital submission may 
be included with the transmission of the digital RT data via sFTP or submitted 
separately. Screen captures are preferred to hard copy for items that are not part of 
the digital plan.  
 
15.6.2 Supportive Data  
•_All diagnostic imaging used to plan the target volume. Digital format is required 
(DICOM).  
•_Radiotherapy record (treatment chart) including prescription and daily and 
cumulative doses to all required areas and organs at risk.  This included copies 
of the procedure notes related to the placement and the removal of the plaque. 
• _If the recommended doses to the organs at risk are exceeded, an explanation 
should be included for review by IROC Rhode Island (QARC) and the radiation 
oncology reviewers.  
 
15.6.3 The Brachytherapy Physics Reporting Form available at www.QARC.org should 
be submitted for all patients treated with radioactive plaque treatment. The 
completed form should be scanned and e-mailed to DataSubmission@QARC.org 
or faxed to IROC Rhode Island (QARC).  
 
IROC Rhode Island (QARC) 

 
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Building B, Suite 201 
640 George Washington Highway 
Lincoln, RI 02865-4207 
Phone: (401) 753-7600 
Fax: 
(401) 753-7601 
 
15.7 
Definition of Deviation in Protocol Performance 
 
Table 15.7 Radiation Therapy Deviation Definitions 
 
 
DEVIATION 
 
Minor 
Major 
Prescription 
Dose 
 
 
Difference in prescribed or 
computed dose is 6-10% of 
protocol specified dose  
 
Difference in prescribed or 
computed dose is > 10% of 
protocol specified dose  
 
Volume 
 
 
3D: 
GTV does not encompass 
MR-visible tumor (gap is  less 
than  2 mm) 
2D:  
Measured tumor thickness is 
less than 2mm different on 
imaging from prescription 
depth 
 
3D: 
GTV does not encompass 
MR-visible tumor (gap is  
more than  2 mm) 
2D:  
Measured tumor thickness is 
more than 2mm different on 
imaging from prescription 
depth 
 
Organs 
at 
Risk 
 
 
 
Dose to any OAR exceeds 
dose listed in table 15.5 by 6-
10%. 
Dose to any OAR exceeds 
dose listed in table 15.5 by > 
10%. 
 
 
 

 
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16.0 
OPHTHALMOLOGIC GUIDELINES  
16.1 
Local Therapy 
Local therapy is used to eradicate local disease after reduction of the tumor volume by 
chemotherapy and may include cryotherapy, green laser, infrared laser and/or radioactive 
plaque. See Section 15.0 for Plaque Guidelines. The goal of local therapy is to achieve Type 
I regression pattern with calcification or Type IV with flat chorioretinal scars, or avascular, 
linear, white gliosis. 
 
16.1.1 Cryoablation 
Cryotherapy can be utilized following the completion of the first cycle of IA 
melphalan, for ablating tumor remnants/recurrences after protocol therapy up to 3 
mm in height that are located at or anterior to the equator. Tumors will be treated 
with 3 freeze-thaw cycles at each session. The ice ball will be allowed to thaw 
completely between freezes. Tumor, including any overlying vitreous seeds, must 
be completely enclosed by ice to be considered treated. If the lesion has an extensive 
base, part of the lesion (up to 4 sites) may be frozen in one session and then the 
additional part of the lesion at a later session with next EUA. It is recommended that 
no more than 4 different sites be frozen in one eye at a single session. The only 
acceptable regression patterns following cryotherapy are either flat chorioretinal 
scars or chorioretinal scars with a central calcific deposit; achieving this may require 
multiple treatments. There is less likelihood of creating vitreous seeds with 
cryotherapy if a tumor has been previously treated with chemotherapy. Extensive 
cryotherapy has been associated with significant persistent retinal detachment, 
particularly if the retina was originally detached prior to chemotherapy. Retinal 
breaks can be caused by cryotherapy. Including calcified Type I regression in the ice 
ball should be avoided if possible. The site of transition between the retina and the 
calcific mass is at risk to develop a retinal break following cryotherapy.  
 
16.1.2 Green Laser Photoablation  
After cycle one of IA melphalan, green laser (argon or 532 nm) can be used to ablate 
tumors up to 8 mm in thickness, especially posterior to the equator following 
chemotherapy. The shorter wave-length 532 nm laser is selected when there is a 
minimal amount of underlying pigmentation to absorb the energy. Through a widely 
dilated pupil, a 500µ spot size is delivered directly to the tumor by indirect 
ophthalmoscopy (the 28D indirect lens gives a larger laser spot on the lesion than 
the 20D lens), at a low energy output, increasing the power by 50 mW increments 
until “blanching” or gentle “whitening” of the tumor occurs. This end-point is 
established at the edge of the tumor with a portion of the spot on the normal retina. 
Begin with a power of 200-300 mW and do not exceed 700 mW or 1000 msec. 
 
The tumor is outlined with burns half on and half off the retina. There should be 30% 
spot overlap. After outlining the tumor, the entire tumor should be covered with 30 
% overlapping spots. The “take” may not be obvious in thicker parts of the tumor. 
Complete coverage is considered “1 laser treatment”. Each numbered lesion should 
receive a minimum of 3 complete “laser treatments” with only one “complete laser 
treatment” given at each EUA. 
 

 
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The response to laser energy depends to a large extent on the amount of pigmentation 
underlying the area being treated. In patients with significant pigmentation, 
relatively little energy is needed to achieve end-point. Within pigmented scars, the 
uptake of energy varies with the amount of pigment and the exposure has to be 
adjusted accordingly. In lightly pigmented fundi, more energy is required to achieve 
end point. Small hemorrhages may occur within tumors. 
 
The immediate response to the green laser is whitening of the retina and tumor. 
Reduced volume and increased translucency of the tumor is considered a good 
outcome response, but a flat scar with pigment epithelial proliferation is preferred. 
Several laser sessions may be required to achieve this. The green laser used with 
excessive power might cause hemorrhage or breaks in Bruch’s membrane. Laser-
induced hemorrhage has been associated with vitreous seeding. Inadequate dilation 
of the pupil can cause laser burns to the iris. 
 
16.1.3 Infrared Laser Photablation 
Infrared laser can be selected to treat RB tumors up to 8 mm thickness that have an 
intact retinal pigment epithelium following IA melphalan. Either the 810 nm diode 
or 1064 nm continuous wave YAG laser apparently has a similar effect on RB 
tumors. Using the operating microscope or indirect ophthalmoscope delivery 
system, a spot size ≥ 1000-2000 µ is applied directly to the tumor. Starting with a 
low power at 1-second durations, the power or time is gradually increased until a 
slight whitening is observed, which is then applied to the entire surface of the tumor. 
Do not exceed 800 MW in power. Although very little response may be seen acutely 
with the infrared laser, subsequent observations will show a decrease in tumor 
volume with good response. Complete response often results in a residual flat mass, 
with a white, gliotic appearance, devoid of tumor vessels. This response may be very 
difficult to interpret and the activity can only be judged by repeated observations. 
The use of excessive power may result in hemorrhage or vitreous dissemination of 
tumor, but starting with low power and gradually increasing avoids these problems. 
 
16.1.4 Plaque Radiotherapy 
Plaque radiotherapy may be used to treat local recurrences up to 8 mm in thickness 
and 15 mm in base. See Section 15.0 for guidelines. Proliferative retinopathy 
secondary to plaque will be monitored on this study, with an early stopping rule if 
incidence is > 15 % (See Statistical Section 9.0). 
 
16.1.5 Frequency of Local Ablative Therapy 
An EUA will then be done within 1 week prior to each cycle of IA melphalan and 
within 4 weeks of completion of the third cycle of IA Melphalan. After completion 
of protocol therapy, an EUA is recommended every 1-4 months until age 3 years, 
then every 4-6 months until age 5 years, then 6-12 months. Patients should be 
transitioned to an office exam without anesthesia when old enough to cooperate in 
an effort to ensure that anterior recurrences are not missed, B-scan ultrasonography 
can be used as an adjunct to the office indirect ophthalmoloscopy when scleral 
depression is not possible.  
 
 
 

 
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APPENDIX I: CLASSIFICATION SYSTEM FOR INTRAOCULAR RETINOBLASTOMA 
 
INTERNATIONAL CLASSIFICATION SYSTEMS FOR INTRAOCULAR RETINOBLASTOMA 
 
Group A 
Small intraretinal tumors away from foveola and disc 
 
• 
All tumors are 3 mm or smaller in greatest dimension, confined to the retina and 
• 
All tumors are located further than 3 mm from the foveola and 1.5 mm from the optic disc 
 
Group B 
All remaining discrete tumors confined to the retina 
 
• 
All other tumors confined to the retina not in Group A 
• 
Tumor-associated subretinal fluid less than 3 mm from the tumor with no subretinal seeding 
 
Group C 
Discrete Local disease with minimal subretinal or vitreous seeding 
 
• 
Tumor(s) are discrete  
• 
Subretinal fluid, present or past, without seeding involving up to 1/4 retina 
• 
Local fine vitreous seeding may be present close to discrete tumor  
• 
Local subretinal seeding less than 3 mm (2 DD) from the tumor 
 
Group D 
Diffuse disease with significant vitreous or subretinal seeding 
 
• 
Tumor(s) may be massive or diffuse  
• 
Subretinal fluid present or past without seeding, involving up to total retinal detachment 
• 
Diffuse or massive vitreous disease may include  “greasy” seeds or avascular tumor masses  
• 
Diffuse subretinal seeding may include subretinal plaques or tumor nodules 
 
Group E 
Presence of any one or more of these poor prognosis features 
 
• 
Tumor touching the lens 
• 
Tumor anterior to anterior vitreous face involving ciliary body or anterior segment 
• 
Diffuse infiltrating retinoblastoma 
• 
Neovascular glaucoma 
• 
Opaque media from hemorrhage 
• 
Tumor necrosis with aseptic orbital cellulites 
• 
Phthisis bulbi 
 
 
 
 

 
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APPENDIX II: GUIDELINES FOR TISSUE HANDLING 
Summary of Tissue Segments to be submitted plus one set of UNSTAINED slides of same cassettes. 
 
1-2 H&E slides: Main A-P P-O segment (Figure 1 P.O.) 
P-O Sections through optic nerve head are mandatory- at least 1 good representative level is 
recommended; if possible 2 levels are preferred. Please refer to “Basic goals of histopathologic 
evaluation” below for comprehensive information. 
 
2 H&E slides: Segments of breadloafed calottes (2 cassettes) (Figure 1- S.C and I.C.) 
 
1 H&E slide: Transverse section of optic nerve from region of true surgical margin (remove and place in 
separate container of fixative prior to harvesting fresh tumor tissue). (Figure 1 O.N.) 
FIGURE 1. 
 
FIXATION, GROSSING AND SUBMISSION FOR HISTOLOGIC EXAMINATION: 
 
Fixation 
The specimen should be fixed immediately after enucleation. Since the eye has failed therapy 
harvesting of fresh tumor is not recommended. The eye should be immersed in a container of 50-100 
mL of 10% Formalin. At least 48 hours of fixation are recommended. Do not open cornea or sclera or 
inject formalin. 
 
Basic Goals of Histopathologic Evaluation 
The histopathology part of this study is designed carefully to assess eyes enucleated for retinoblastoma 
for the presence certain histopathologic features that are known or suspected to affect prognosis 
adversely and to evaluate the changes associated to intra-arterial chemotherapy. 
 

 
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These include: 
• 
The presence or absence of tumor in the optic nerve surgical margin. 
• 
The presence and depth of optic nerve invasion, especially the presence of retrolaminar nerve 
 
invasion 
• 
The presence and degree of uveal stromal invasion i.e. infiltration of the stroma of the choroid, 
 
ciliary body and/or iris, including the presence of grossly visible or massive invasion. For the 
 
purpose of this study massive invasion is defined as follows 
 
I: Posterior uveal invasion absent 
 
II: Posterior uveal invasion present 
IIA: Largest dimension of intrachoroidal tumor on slide less than 1 mm 
 
IIB: Largest dimension between 1-3 mm 
 
IIC: Largest dimension greater than 3 mm (MASSIVE) 
 
IID: Posterior uveal tumor noted grossly (MASSIVE) 
 
The presence of extraocular extension and orbital invasion 
 
Treatment Effect 
• 
Other histologic features with potential prognostic significance include invasion of the anterior 
 
chamber and trabecular meshwork, and invasion of the scleral and scleral emissarial canals. 
• 
Changes in the tumor (calcification, giant cells, macrophages, necrosis) 
• 
Changes in retina and choroid (vascularization, necrosis, atrophy, ischemic changes, 
 
inflammation) 
• 
Changes in optic nerve vasculature and cellularity 
• 
Foreign body reaction in any structure of the eye 
• 
Anterior chamber changes (cataract, neovascularization of iris) 
• 
Vascular changes 
 
Grossing Eyes: General Principles and Technique 
 
The P-O Segment 
Routinely, histologic sections of eyes are cut from a paraffin block that includes a short cylindrical 
anteroposterior segment of the globe called the P-O or pupil-optic nerve segment. The P-O segment 
includes most of the cornea, iris and pupil anteriorly and the optic nerve posteriorly (Figure 1 & 3). 
 
The Calottes 
The dome-shaped caps of tissue that are removed when the P-O segment is prepared are called calottes 
(French for visor-less cap). The first calotte should include about one-fourth or one-fifth of the 
peripheral anterior chamber. The first calotte should also include the scleral window if one has been 
performed (Figure 1& 3). 
 
Standard Measurements 
Before the globe is opened, a standard series of measurements are made using a caliper or a millimeter 
rule. The A-P (anteroposterior including the cornea) and the horizontal and vertical dimensions 
(viewed from the front) are measured and recorded in that order. The length of the attached 
segment of optic nerve is also recorded. The horizontal and vertical diameter of the cornea and the 
diameter of the pupil also are recorded (Figure 2). The iris color is also noted. 
 
 
Globe: AP, Horizontal, Vertical, length of optic nerve. 
 
Cornea- horizontal and vertical 
 
Diameter of pupil 
 
Other Lesions of interest- (if any, approximate dimension of intraocular tumor.) 

 
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FIGURE 2 
 
Preparing the main P-O Segment 
Eyes should be carefully sectioned using a standard double-edge razor blade or half a blade, which has 
been snapped in half within its protective wrapper. The two ends of the blade are held between the 
apposed surfaces of the thumb and forefinger. The blade is oriented perpendicular to the dissector’s 
chest and a gentle sawing motion is used. A scalpel should never be used to open an eye because it 
tends to indent and compress the eye too forcefully (Figure 3). 
 
 
 
FIGURE 3 
 
Removing the First Calotte 

 
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During the initial cut (removal of the first calotte), the eye is placed corneal side-down on the cutting 
block and steadied with the non-dominant hand. Guidelines drawn on the eye with colored pencil 
facilitate sectioning and help to assure that the eye is oriented properly prior to sectioning. The incision 
is started posteriorly and extended anteriorly. At the start of the incision, the blade is positioned close to 
the optic nerve, but external to its dural sheath. A gentle sawing motion is used. Try not to bend the 
blade during sectioning. In addition, care must be taken to avoid compressing the eye too forcefully, as 
this can collapse the eye and express the tumor and intraocular contents. The cut should enter the 
periphery of the anterior chamber anteriorly. The first calotte should include about one-fifth to one-
fourth of the peripheral anterior chamber (Figure 3A). 
 
Stereomicroscopic Examination 
After the first calotte is removed, the eye should be examined with a dissecting microscope. If uveal 
invasion by tumor is noted or suspected grossly it should be documented. 
 
Removing the Second Calotte 
The second calotte is then removed. This is most easily done by placing the eye cut-surface down on 
the cutting block, and making a second parallel cut (Figure 3B-D). 
 
The main PO segment is submitted. At least two levels comprising 10 slides each that include the 
central portion of the optic nerve head should be cut. 
 
Submission of Additional Tissue Segments from the Calottes to Exclude Uveal Invasion. 
It is extremely important to examine the residual tissue in the calottes to exclude uveal stromal 
invasion that may not be evident grossly. 
Both calottes should be sectioned in a “breadloaf” fashion and submitted entirely (Figure 3E-F). 
If a significant amount of tumor is present in a calotte, one may choose to prepare an addition A-P 
segment of the entire globe prior to preparing the breadloafed segments. 
 
 
 

 
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