Assessed for eligibility (N = 600)

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Assessed for eligibility (N = 600) Excluded first wave (n = 46) Bilateral advanced RB (n = 44) Died from chemotherapy toxicity (n = 2) Studied for effect of delayed enucleation on mortality (n = 554) IIRC Group D (n = 202) Died from RB metastasis (n = 6) IIRC Group E (n = 352) Died from RB metastasis (n = 16) Excluded second wave (n = 44) Received < 1 cycle of pre-enucleation chemotherapy (n = 15) Received non-systemic chemotherapy salvage therapy (n = 29) Intra-arterial chemotherapy (n = 18) Pars plana vitrectomy endoresection (n = 6) Plaque radiotherapy (n = 3) Stem cell transplantation (n = 1) Immunotherapy (n = 1) Fig 1. CONSORT diagram. Studied for effect of pre-enucleation systemic chemotherapy on mortality (n = 510) IIRC Group D (n = 177) Died from RB metastasis (n = 4) IIRC Group E (n = 333) Died from RB metastasis (n = 16)

A B Children with IIRC group D eyes Children with IIRC group E eyes < 3.5 months from diagnosis to enucleation < 2 months from diagnosis to enucleation > 3.5 months from diagnosis to enucleation > 2 months from diagnosis to enucleation Log-rank P = .018 Log-rank P = .017 Fig 2. Kaplan-Meier curves of disease-specific survival (DSS) of children with enucleated groups D and E eyes. (A) DSS of children with group D eyes enucleated < 3.5 months and > 3.5 months from diagnosis. (B) DSS of children with group E eyes enucleated < 2 months and > 2 months from diagnosis. No. at risk < 3.5 months dx to enu 97 93 89 72 20 > 3.5 months dx to enu 105 99 92 66 17 1 No. at risk < 2 months dx to enu 268 227 212 174 68 6 > 2 months dx to enu 84 75 65 56 34 1

Primary enucleation 1 to 3 cycles of pre-enucleation chemotherapy ≥ 4 cycles of pre-enucleation chemotherapy Log-rank P = .031 No. at risk Primary enucleation 214 182 173 139 44 6 1 to 3 cycles of chemotherapy 72 60 55 50 33 ≥ 4 cycles of chemotherapy 47 42 30 20 1 Fig 3. Kaplan-Meier curves and Cox proportional hazard model of disease-specific survival of children with enucleated group E eyes who received primary enucleation, 1 to 3 cycles of pre-enucleation chemotherapy and ≥ 4 cycles of pre-enucleation chemotherapy. Group n Events HR (95% CI) P Primary enucleation 214 8 0.77 (0.16 to 3.61) .74 1 to 3 chemotherapy cycles 72 2 3.35 (1.16 to 9.67) .025 ≥ 4 chemotherapy cycles 47 6

Low-risk eyes without pre-enucleation chemotherapy Low-risk eyes with pre-enucleation chemotherapy High-risk eyes without pre-enucleation chemotherapy High-risk eyes with pre-enucleation chemotherapy Log-rank P < .001 No. at risk LR eyes w/o chemo 196 176 170 136 41 5 LR eyes w/ chemo 208 191 146 73 2 HR eyes w/o chemo 79 64 59 46 13 1 HR eyes w/ chemo 27 21 14 10 Fig 4. Kaplan-Meier curves and Cox proportional hazard model of disease-specific survival of children with enucleated low-risk (LR) and high-risk (HR) eyes who received pre-enucleation chemotherapy compare with those who did not. Group n Events HR (95% CI) P LR eyes w/o chemo 196 2 0.94 (0.13 to 6.70) .95 LR eyes w/ chemo 208 HR eyes w/o chemo 79 6 5.21 (1.89 to 14.29) < .001 HR eyes w/ chemo 27 10

Low-risk eyes without post-enucleation chemotherapy Low-risk eyes with post-enucleation chemotherapy High-risk eyes without post-enucleation chemotherapy High-risk eyes with post-enucleation chemotherapy Log-rank P < .001 No. at risk LR eyes w/o chemo 291 268 252 197 45 2 LR eyes w/ chemo 151 135 129 114 76 5 HR eyes w/o chemo 15 11 6 3 HR eyes w/ chemo 97 80 71 54 18 1 Fig A1. Kaplan-Meier curves and Cox proportional hazard model of disease-specific survival of children with enucleated low-risk (LR) and high-risk (HR) eyes who received post-enucleation chemotherapy compare with those who did not. Group n Events HR (95% CI) P LR eyes w/o adjuvant chemo 291 4 0.49 (0.054 to 4.35) .52 LR eyes w/ adjuvant chemo 151 1 HR eyes w/o adjuvant chemo 15 7 0.20 (0.074 to 0.52) .001 HR eyes w/ adjuvant chemo 97 10