Metastatic Death Based on Presenting Features and Treatment for Advanced Intraocular Retinoblastoma: A Multicenter Registry-Based Study

Magnetic resonance features in advanced retinoblastoma - what a paediatric radiologist needs to know

Retinoblastoma is the most common intra-ocular malignancy in children worldwide. Current treatment modalities include focal therapy such as laser or cryotherapy, intravenous chemotherapy, intra-arterial chemotherapy and surgical enucleation. According to the current retinoblastoma staging systems, there are a few common features indicating advanced disease stage, which can subsequently predict the prognosis and the necessity of surgical enucleation and adjuvant chemotherapy. This review uses annotated magnetic resonance (MR) images to illustrate these features, which include (1) retinal detachment, (2) vitreous and subretinal seeding, (3) choroidal invasion, (4) anterior segment invasion and increase in intra-ocular pressure, (5) iris neovascularization, (6) vitreous haemorrhage, (7) aseptic orbital cellulitis with lens dislocation, (8) post-laminar optic nerve invasion and (9) distant and systemic metastasis. Prompt identification of these features is important for paediatric radiologists to guide the clinical team for appropriate management.

NEOVASCULAR GLAUCOMA AS A PREDICTOR OF RETINOBLASTOMA HIGH-RISK HISTOPATHOLOGY IN AN INTERNATIONAL MULTICENTER STUDY

PURPOSE

To assess histopathology and outcomes after primary enucleation of eyes with retinoblastoma presenting with neovascular glaucoma (NVG).

METHODS

This was an international multicenter case series study across five continents. A retrospective review of patient charts was performed for all patients undergoing primary enucleation for retinoblastoma (n = 1,420) using a standardized data-collection spreadsheet. Clinical features, pathologic grade, and outcomes were compared between NVG patients and those with an American Joint Commission on Cancer eighth edition clinical stage of cT2. High-risk histopathology was defined as American Joint Commission on Cancer eighth edition pathologic stage ≥ pT2b.

RESULTS

Neovascular glaucoma was seen in 224/1,420 (16%) patients. The mean age at presentation of those with NVG was 30 months (median 25, range 0-120 months), and 131 (58%) patients had high-risk histopathology. The univariate logistic regression odds ratio for NVG predicting high-risk histopathology was 1.73 (95% confidence interval: 1.3-2.31) and from multivariate logistic regression was 1.77 (95% confidence interval: 1.23-2.56). Patients with a longer duration of symptoms ( P = 0.03), buphthalmos ( P = 0.02), and ectropion uveae ( P < 0.01) were more likely to have high-risk histopathology. Patients with NVG were more likely to develop metastasis than cT2 patients ( P = 0.04).

CONCLUSION

There is a significant association between NVG at presentation, high-risk histopathology, and metastatic risk.

Intraarterial Chemotherapy for Retinoblastoma, Outcomes Analysis in 357 Eyes: Thirteen Years of Experience in a Referral Center in Brazil

OBJECTIVE

To evaluate the outcomes of intraarterial chemotherapy (IAC) for the treatment of naive and nonnaive retinoblastoma eyes. Ocular survival rates, risk factors for enucleation, ocular complications, metastatic disease, and overall survival were analyzed.

DESIGN

A retrospective, single-institution study.

PARTICIPANTS

A total of 300 patients treated with IAC between April 2010 and April 2023 were included.

INTERVENTIONS

During IAC infusions, 1 to 3 drugs were used (melphalan, 3.0-7.5 mg; topotecan, 0.3-2.0 mg; and carboplatin, 20-50 mg). Adjuvant therapy was used as needed to consolidate treatment.

MAIN OUTCOME MEASURES

Ocular survival rates, ocular complications, and the risk factors for enucleation were measured.

RESULTS

A total of 357 eyes were treated with 1536 IAC infusions, with a median of 4 cycles per eye, and followed for 60.69 months. The Kaplan-Meier estimates for the overall ocular survival were 90% at 1 year, 89% at 2 years, and 86% at 5 years. No difference in ocular survival was found between IAC indications (primary 88% vs. secondary 85% vs. bridge 89%; P = 0.52) and the use of tandem therapy (tandem 85% vs. no tandem 87%; P = 0.93). Intravitreal chemotherapy was used as adjuvant therapy in 31.37% and plaque therapy in 5% of the eyes. The group did not receive external beam radiation. Univariable and multivariable analyses showed that the presence of subretinal seeds was significantly associated with an increased risk of enucleation, and the use of ophthalmic artery (OA) ostium in >50% of infusions per eye was a protective factor to avoid enucleation. Retinal and choroidal vascular, ischemic, or atrophic effects were the most frequent complications found in 5.0% of the eyes. Metastatic disease was observed in 0.33% of the patients. The overall 5-year patient survival was 99.3%.

CONCLUSIONS

The use of IAC in different indications (primary, secondary, bridge, and tandem) to treat naive or recurrent-refractory retinoblastomas showed successful results. Most eyes were preserved. Subretinal seeds at presentation were associated with a high enucleation risk. The use of the OA ostium for drug delivery avoided enucleation.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

High-Risk Retinoblastoma Based on International Classification Systems: Analysis of 1362 Eyes

PURPOSE

To determine the predictive value of International Intraocular Retinoblastoma Classification schemes and the American Joint Committee on Cancer (AJCC) classification for histopathological high-risk features (HRFs).

DESIGN

Multicentric international collaborative retrospective case series.

SUBJECTS

One thousand three hundred and sixty-two patients with retinoblastoma from 16 centers and 11 countries.

INTERVENTION

Primary enucleation; adjuvant therapy in patients with HRF.

MAIN OUTCOME MEASURES

High-risk retinoblastoma defined as 1 or more HRF (anterior segment involvement, massive choroidal invasion, minor choroidal infiltration with prelaminar optic nerve invasion, retrolaminar or resected optic nerve cut end involvement, scleral or microscopic extrascleral infiltration); metastasis-free survival (MFS).

RESULTS

Of the 1362 patients, 751 (55.1%) had HRF. According to the International Classification of Retinoblastoma (ICRB) (Philadelphia vs. Los Angeles [LA]) versus Children's Oncology Group (COG) classification schemes, the positive predictive value (PPV) of group D eyes for HRF was 42.0% versus 35.1% versus 43.2%, respectively, and that for group E eyes was 58.5% versus 59.0% versus 59.5%, respectively. Comparing group D versus group E eyes, there was higher mean number of HRF (standard deviation, range) among group E eyes using the ICRB Philadelphia (0.7 [0.9, 0.0-6.0] vs. 1.3 [1.7, 0.0-9.0], P < 0.001), ICRB LA (0.6 [0.8, 0.0-6.0] vs. 1.3 [1.7, 0.0-9.0], P < 0.001) and COG (0.8 [1.2, 0.0-7.0] vs. 1.3 [1.6, 0.0-8.0], P < 0.001) classifications. The PPV for HRF was above 55% for AJCC clinical tumor (cT) group cT3a with increments through cT3e to 72.3%. An agreement between ICRB Philadelphia versus ICRB LA, ICRB LA versus COG, and ICRB Philadelphia versus COG was 0.9, 0.8, and 0.8, respectively (P < 0.001). Metastasis-free survival rates and overall survival rates were also comparable between all intraocular retinoblastoma classification schemes but better stratified within the AJCC scheme.

CONCLUSIONS

All intraocular retinoblastoma classification schemes predict HRF and MFS equally. Group E includes a wide spectrum equivalent to the AJCC group cT3. Uniform grouping with subcategorization of group E might improve risk stratification. We propose that everyone across the retinoblastoma world henceforth adopts the AJCC classification for all reporting and publishing.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Risk Factors for Extraocular Relapse in Retinoblastoma

BACKGROUND

Metastatic retinoblastoma remains a significant challenge in pediatric oncology, with stark disparities in survival outcomes between high-income countries (HICs) and low-income countries (LICs). Delayed diagnosis and treatment, driven by socioeconomic factors and limitations in healthcare systems, contribute to poorer outcomes in LICs. Histopathological characteristics, including high-risk pathology factors (HRPFs) and the extent of ocular tumor invasion, are critical for predicting metastatic risk and guiding treatment strategies.

METHODS

This review examines the role of clinical, histopathological, and molecular characteristics in assessing metastatic risk in retinoblastoma. Literature on HRPFs, tumor invasion, and molecular subtypes was analyzed to understand their impact on risk stratification and therapy optimization, particularly in resource-limited settings.

RESULTS

Retinoblastoma is increasingly recognized as a heterogeneous disease with at least two distinct molecular subtypes. High-risk cases frequently exhibit genetic alterations that underscore the need to incorporate molecular profiling into risk assessment. Current adjuvant therapy approaches, however, vary widely, and debates persist regarding their necessity based on tumor characteristics. Integrated strategies that combine clinical, histopathological, and molecular data show promise in improving management and survival outcomes.

CONCLUSIONS

Addressing the disparities in metastatic retinoblastoma outcomes requires a multifaceted approach. By integrating clinical, histopathological, and molecular insights, management strategies can be optimized to improve survival, particularly in resource-limited settings where challenges are most pronounced.

In vitro model of retinoblastoma derived tumor and stromal cells for tumor microenvironment (TME) studies

Retinoblastoma (RB) is an intraocular tumor arising from retinal cone progenitor cells affecting young children. In the last couple of years, RB treatment evolved towards eye preserving therapies. Therefore, investigating intratumoral differences and the RB tumor microenvironment (TME), regulating tumorigenesis and metastasis, is crucial. How RB cells and their TME are involved in tumor development needs to be elucidated using in vitro models including RB derived stromal cells. In the study presented, we established primary RB derived tumor and stromal cell cultures and compared them by RNAseq analysis to identify their gene expression signatures. RB tumor cells cultivated in serum containing medium were more differentiated compared to RB tumor cells grown in serum-free medium displaying a stem cell like phenotype. In addition, we identified differentially expressed genes for RB tumor and stromal derived cells. Furthermore, we immortalized cells of a RB1 mutated, MYCN amplified and trefoil factor family peptid 1 (TFF1) positive RB tumor and RB derived non-tumor stromal tissue. We characterized both immortalized cell lines using a human oncology proteome array, immunofluorescence staining of different markers and in vitro cell growth analyses. Tumor formation of the immortalized RB tumor cell line was investigated in a chicken chorioallantoic membrane (CAM) model. Our studies revealed that the RB stromal derived cell line comprises tumor associated macrophages (TAMs), glia and cancer associated fibroblasts (CAFs), we were able to successfully separate via magnetic cell separation (MACS). For co-cultivation studies, we established a 3D spheroid model with RB tumor and RB derived stromal cells. In summary, we established an in vitro model system to investigate the interaction of RB tumor cells with their TME. Our findings contribute to a better understanding of the relationship between RB tumor malignancy and its TME and will facilitate the development of effective treatment options for eye preserving therapies.

Mutational analysis of the RB1 gene in patients with unilateral retinoblastoma

Purpose

Retinoblastoma, a childhood cancer originating in the retina, is primarily attributed to pathogenic RB1 mutations The aim of this study is to conduct a mutational analysis of the RB1 gene in cases of unilateral Retinoblastoma among individuals within the Jordanian population.

Methods

In this study, the peripheral blood of 50 unilateral Rb patients was collected, genomic DNA was extracted, and mutations were identified using Next Generation Sequencing (NGS) analysis.

Results

In this cohort of 50 unrelated patients with unilateral Rb, the median age at diagnosis was eight months (mean, 12 months; range; 2 weeks to 54 months). Twenty-eight (56%) were males, 29 (58%) had the disease in the right eye, 3 (6%) had a positive family history of Rb, and 20 (40%) were diagnosed within the first year of life. RB1 gene pathogenic mutations were detected in 14 out of 50 (28%) patients, indicating germline disease. Among unilateral non-familial cases, 11 out of 47 (23%) were found to have germline RB1 mutations. Overall, five (36%) of the germline cases had the same mutation detected in one of the parents consistent with an inherited disease (four (80%) were of paternal origin); 3 (60%) of these had affected carrier parent, two (40%) had an unaffected carrier parent. Nine (64%) patients had the nonsense mutation, and six (43%) had the mosaic mutation. The significant prognostic factors for positive genetic testing were positive family history (p = 0.018) and age at diagnosis less than 12 months (p = 0.03). At a median of 54 months follow-up, two (4%) patients were dead from distant metastasis. The overall eye salvage rate was 44% (n = 22/50) eyes; 100% for groups A, B, and C, 60% for group D, and none for group E eyes. There was no correlation between the presence of germline mutation and outcome in terms of eye salvage, metastasis, and survival.

Conclusion

In this study, 28% of patients with unilateral Rb had germline RB1 mutations, of which 43% were inherited, and one-third presented beyond their first year of life. Therefore, molecular screening is critical for genetic counseling regarding the risk for inherited Rb in unilateral cases, including those with no family history, regardless of the age at diagnosis. However, germline mutations did not appear to significantly predict patient outcomes regarding eye salvage, metastasis, and survival.

Retinoblastoma - A comprehensive review, update and recent advances

Retinoblastoma is the most common pediatric ocular malignancy. It is triggered by a biallelic mutation in the RB1 gene or MYCN oncogene amplification. Retinoblastomas can be unilateral (60%-70%) or bilateral (30%-40%); bilateral tumors are always heritable and present at an earlier age as compared to unilateral ones (18-24 months vs. 36 months in India). High prevalence rates, delayed presentation, and inaccessibility to healthcare lead to worse outcomes in developing countries. The past few decades have seen a paradigm change in the treatment of retinoblastomas, shifting from enucleation and external beam radiotherapy to less aggressive modalities for eye salvage. Multimodality treatment is now the standard of care and includes intraarterial or intravenous chemotherapy along with focal consolidation therapies such as transpupillary thermotherapy, cryotherapy, and laser photocoagulation. Intravitreal and intracameral chemotherapy can help in controlling intraocular seeds. Advanced extraocular or metastatic tumors still have a poor prognosis. Genetic testing, counseling, and screening of at-risk family members must be incorporated as essential parts of management. A better understanding of the genetics and molecular basis of retinoblastoma has opened up the path for potential targeted therapy in the future. Novel recent advances such as liquid biopsy, prenatal diagnosis, prognostic biomarkers, tylectomy, and chemoplaque point to promising future directions.

Global retinoblastoma studies: A review

In the current era of global health awareness for retinoblastoma (RB), the challenge that lies ahead of us is providing optimal care for children affected with RB in underdeveloped nations. The understanding of similarities and disparities between various nations across the world aids in achieving comparable outcomes. With dissolving geographic barriers and evolving collaboration, global collaborative studies on RB are becoming increasingly common. They provide real-world, robust evidence on several aspects of RB. This review discusses insights gained from global RB studies regarding the demographics, certain aspects of etiopathogenesis and epidemiology, international travel burden, disparities in clinical presentations based on national income levels, management protocols, pathology, treatment outcomes, and the effect of COVID-19 on RB care across the world. These insights are likely to impact individual practice as well as inform policy reforms.

Diagnostic Imaging for Retinoblastoma Cancer Staging: Guide for Providing Essential Insights for Ophthalmologists and Oncologists

Retinoblastoma is the most common cause of all intraocular pediatric malignancies. It is caused by the loss of RB1 tumor suppressor gene function, although some tumors occur due to MYCN oncogene amplification with normal RB1 genes. Nearly half of all retinoblastomas occur due to a hereditary germline RB1 pathogenic variant, most of which manifest with bilateral tumors. This germline RB1 mutation also predisposes to intracranial midline embryonal tumors. Accurate staging of retinoblastoma is crucial in providing optimal vision-, eye-, and life-saving treatment. The AJCC Cancer Staging Manual has undergone significant changes, resulting in a universally accepted system with a multidisciplinary approach for managing retinoblastoma. The authors discuss the role of MRI and other diagnostic imaging techniques in the pretreatment assessment and staging of retinoblastoma. A thorough overview of the prevailing imaging standards and evidence-based perspectives on the benefits and drawbacks of these techniques is provided. Published under a CC BY 4.0 license. Test Your Knowledge questions for this article are available in the supplemental material.

Ten-year experience with intracameral chemotherapy for aqueous seeding in retinoblastoma: long-term efficacy, safety and toxicity

AIMS

To report long-term results of intracameral chemotherapy (ICC) for aqueous seeding (AS) in retinoblastoma.

METHODS

Retrospective study including 20 patients with primary (n=4) or secondary non-iatrogenic (n=16) AS treated with ICC according to a previously described technique between 2011 and 2020 with at least 1-year follow-up.

RESULTS

AS control was initially achieved in all cases with a mean 5 injections of melphalan (n=13) or topotecan (n=7). Three eyes had an isolated AS relapse at a mean interval of 8 months after the first ICC course, which regressed with a second course of intracameral melphalan. Concomitant interciliary process seed implantation was treated with additional brachytherapy if sectorial (n=3) or proton therapy if annular (n=1). Other therapies including systemic, intra-arterial chemotherapy and/or focal treatments were given in 15 eyes to treat concomitant tumour sites. Eye preservation was achieved in 85% of the eyes (n=17/20) at a mean event-free follow-up of 45 months for aqueous disease, and 40 months for any other intraocular tumour activity. Three cases were enucleated due to refractory non-aqueous disease. All patients are alive without metastasis (mean follow-up of 48 months after first ICC). ICC-related intraocular toxicity included iris atrophy (n=5), cataract (n=4), posterior synechiae (n=2) and iris heterochromia (n=1). No patient suffered irreversible vision loss. Useful to normal vision was found in 82% of the cases (n=14/17).

CONCLUSION

ICC appears to be safe and efficient for AS without irreversible vision-threatening adverse effects. More data are needed to determine any superiority in efficiency/toxicity of topotecan versus melphalan.

Establishment and Comprehensive Characterization of a Novel Preclinical Platform of Metastatic Retinoblastoma for Therapeutic Developments

Purpose

Although there have been improvements in the management of metastatic retinoblastoma, most patients do not survive, and all patients suffer from multiple short- and long-term treatment toxicities. Reliable and informative models to assist clinicians are needed. Thus we developed and comprehensively characterized a novel preclinical platform of primary cell cultures and xenograft models of metastatic retinoblastoma to provide insights into the molecular biology underlying metastases and to perform drug screening for the identification of hit candidates with the highest potential for clinical translation.

Methods

Orbital tumor, bone marrow, cerebrospinal fluid, and lymph node tumor infiltration specimens were obtained from seven patients with metastatic retinoblastoma at diagnosis, disease progression, or relapse. Tumor specimens were engrafted in immunodeficient animals, and primary cell lines were established. Genomic, immunohistochemical/immunocytochemical, and pharmacological analysis were performed.

Results

We successfully established five primary cell lines: two derived from leptomeningeal, two from orbital, and one from lymph node tumor dissemination. After the intravitreal or intraventricular inoculation of these cells, we established cell-derived xenograft models. Both primary cell lines and xenografts accurately retained the histological and genomic features of the tumors from which they were derived and faithfully recapitulated the dissemination patterns and pharmacological sensitivity observed in the matched patients.

Conclusions

Ours is an innovative and thoroughly characterized preclinical platform of metastatic retinoblastoma developed for the understanding of tumor biology of this highly aggressive tumor and has the potential to identify drug candidates to treat patients who currently lack effective treatment options.

Causes of death and survival analysis for patients with retinoblastoma in Jordan

Purpose

To analyze causes and prognostic factors for death among Retinoblastoma (Rb) patients treated at a single specialized tertiary cancer center in Jordan.

Methods

We reviewed the mortality causes for all Rb patients who have been treated at the King Hussein Cancer Center between 2003 and 2019 and were followed for at least 3 years after diagnosis. The main outcome measures included demographics, laterality, tumor stage, treatment modalities, metastasis, survival, and causes of death.

Results

Twenty-four (5%) of the 478 patients died from retinoblastoma and 5-year survival was 94%. The mean age at diagnosis was 15 months (median, 18 months; range, 4-38 months); eight (33%) received diagnoses within the first year of life. Eleven (46%) were boys, 16 (67%) had bilateral disease, and 3 (13%) had a positive family history. The stage for the worst eye was C for 1 (4%) patient, D in 6 (25%) patients, and E (T3) in 15 (63%) patients. Two patients had extraocular Rb at diagnosis, and four of the patients who had intraocular Rb at diagnosis refused treatment and then came back with extraocular Rb. In total, extraocular disease was encountered in six eyes (six patients). After a 120-month median follow-up period, 24 patients (5%) died of second neoplasms (n = 3) or metastases (n = 21). Significant predictive factors for metastasis and death included advanced IIRC tumor stage (p < 0.0001), the presence of high-risk pathological features in the enucleated eyes (p = 0.013), parental refusal of the recommended primary treatment plan (p < 0.0001), and extraocular extension (p < 0.0001).

Conclusion

The 5-year survival rates of Rb patients in Jordan are as high as those in high-income countries. However, 5% are still dying from metastatic disease, prompting the need for awareness campaigns to educate the public about the high cure rates and to prevent treatment abandonment.

Presentation and management outcomes of Retinoblastoma among Syrian refugees in Jordan

Purpose

The humanitarian crisis in Syria has had a profound impact on the entire region. In this study, we report the patterns of presentation and management outcomes of Syrian patients with Retinoblastoma (Rb) treated at a single tertiary cancer center in Jordan.

Methods and Materials

This is a retrospective comparative study of Syrian refugees and Jordanian citizens who had Rb between 2011 and 2020. Collected data included patient demographics, presentation, tumor stage, treatment modalities, eye salvage rate, metastasis, and mortality.

Results

Thirty Syrian refugees (16 (53%) had bilateral disease) and 124 Jordanian citizens (51(41%) had bilateral disease) were diagnosed with Rb during this period. The median age at diagnosis for refugees was 10 and 32 months for patients with bilateral and unilateral Rb consecutively, compared to 6 and 28 months for citizens. The median lag time between signs of disease and initiation of treatment was 3 months for refugees, compared to 1 month for citizens.Refugees were more likely to present with a more advanced stage (p=0.046). Out of 46 affected eyes in refugees; 32 (70%) eyes were group D or E, while out of 175 affected eyes among citizens; 98 (56%) eyes were group D or E. Therefore, refugees with Rb were more likely to mandate primary enucleation (48%) compared to citizens (25%) (p=0.003). However, out of 24 eyes among refugees who received conservative therapy, 15 (62%) eyes were successfully salvaged, while out of 131 affected eyes among citizens who received conservative therapy, 105 (80%) eyes were successfully salvaged (p=0.06). Two (7%) of the refugees and four (3.2%) of the citizens with Rb died from metastasis.

Conclusion

Syrian refugees with Rb presented with more advanced disease due to delay in diagnosis and referral that increased the treatment burden by decreasing the chance for eye globe salvage. However, patients who received the timely intervention had a similar outcome to citizens with Rb; probably a reflection of the management of all patients at a single specialized center. We advocate for the timely referral of refugees with this rare life-threatening tumor to a specialized cancer center for the best possible outcome.