Retinoblastoma in an adult: case report and literature review

Retinoblastoma in Adults: Clinical Features, Gene Mutations and Treatment Outcomes: A Study of Six Cases

Purpose

To report six Asian adult patients with retinoblastoma (RB).

Design

Retrospective and observational small case series.

Participants

Six patients with a white dome-shaped tumor of the retina were evaluated from May 10, 1995, to September 10, 2021.

Main Outcome Measures

Initial tumor and associated fundus features, pathology, gene mutation, treatment, tumor course on follow-up, and salvage globe outcome.

Results

The six affected Asian patients consisted of three men and three women. The mean age at the time of diagnosis was 36.5 years (median: 31 years, range: 20-55 years). All patients were unilateral. In all cases, the tumors were white, dome-shaped, with full-thickness retinal involvement, and mushroom-like protrusions into the vitreous cavity. The mean tumor thickness measured by ultrasonography was 4.5 mm (median: 3.2 mm, range: 3.2-6.8 mm). Associated characteristic symptoms included dilated retinal feeding artery and draining vein (100%), surrounding subretinal infiltration (83%), exudative retinal detachment (83%), and vitreous seeds (67%). Local tumor resection was performed in three patients, I-125 plaque brachytherapy combined with transpupillary thermotherapy (TTT) and intravitreous injection of melphalan (combination treatment) in one patient, I-125 plaque brachytherapy in two patients, and enucleation in one (20%) patient. RB1 gene testing was carried out on four patients and pathological diagnosis on five patients. Genetic analysis revealed that the RB1 mutation was a mosaic c.709dupG (p.Glu237GlyfsTer4) duplication in one patient, a mosaic c.763C>T(p.Arg255Ter) mutation in another patient, while the remaining two patients were RB1 negative. At the end of the follow-up, none of the patients had developed tumor-related metastasis or died. The findings were consistent in all patients who had an adequate follow-up. This study focused on this rare lesion to distinguish it from other intraocular white lesions in adults, including choroidal osteoma, vitreoretinal lymphoma, and retinal capillary hemangioma, all of which are different clinical entities.

Conclusion

In adults, RB is typically a white, full-thickness retinal mass that is unilateral, often combining with retinal feeding vessels, subretinal infiltration, and vitreous seeds. Genetic studies on adult-onset RB are essential and still require elucidation. Despite RB being a malignant tumor, patient survival was minimally affected.

Adult presentation of retinoblastoma in Saudi patient

To describe an unusual case of retinoblastoma in adult Saudi. A 21-year-old Saudi male developed acute unilateral visual loss due to a large intraocular lesion in his left eye. Within five days of presentation, the tumor enlarged rapidly causing angle closure glaucoma and orbital cellulitis like picture. The patient underwent enucleation and the histopathology specimen confirmed the presence of an undifferentiated type tumor cell that was consistent with retinoblastoma with choroidal and optic nerve invasion. Retinoblastoma should be considered in the differential diagnosis of an intraocular mass in adults. To the best of our knowledge, this is the first reported case of an adult presentation of retinoblastoma in Saudi patient.

Clinical Features and Long-Term Follow-Up of Patients with Retinoblastoma in Turkish Children Older Than 5 Years of Age

Purpose

The diagnosis and management of retinoblastoma can be difficult in older children. This study reports the clinical features and long-term outcomes of such patients in a Turkish patient population.

Methods

Medical records of 18 patients, between January 1992 and December 2017, were reviewed retrospectively.

Results

Of 298 consecutive patients with retinoblastoma, 18 (6%) were at the age of 5 years and older. The median age at diagnosis was 9 years (range, 5–18 years). Misdiagnosis was noted in 8 patients (44.4%). Treatment options included enucleation in 16 patients (88.8%), adjuvant systemic chemotherapy in 3 (16.6%), intra-arterial chemotherapy in one (5.5%), and additional orbital irradiation in one (5.5%). After a median follow-up of 97 months (range, 6–252 months), all patients survived without any recurrence.

Conclusions

Our series showed that 6% of patients with retinoblastoma were 5 years of age and older. Over a 15-year period, ocular salvage rate of 11.2% and survival rate of 100% were attained.

Retinoblastoma in an Adult

Retinoblastoma is a rare malignant tumor of the retina usually seen in children before 5 years of age. The tumor is extremely rare in adults. We report here an unusual case of retinoblastoma in a 55-year-old adult female who presented to us with an orbital mass at a late stage of the disease. Detailed laboratory investigations and imaging studies could not make a precise diagnosis. The treating ophthalmologist suspected primary intraocular tumor, metastatic carcinoma, malignant melanoma, or lymphoma and referred the patient for fine needle aspiration cytology (FNAC). Cytopathological examination of Giemsa-stained FNAC smear was consistent with that of retinoblastoma and established the diagnosis.

Adult onset retinoblastoma

Retinoblastoma (RB) is the most common primary malignant intraocular tumor of childhood presenting usually before 5 years of age. RB in adults older than 20 years is extremely rare. A literature search using PubMed/PubMed Central, Scopus, Google Scholar, EMBASE, and Cochrane databases revealed only 45 cases till date. Over the past decade, there has been a significant increase in the number of such reports, indicating heightened level of suspicion among ophthalmologists. Compared to its pediatric counterpart, adult onset RB poses unique challenges in diagnosis and treatment. This article summarizes available literature on adult onset RB and its clinical and pathologic profile, genetics, association with retinocytoma, diagnostics, treatment, and outcomes.

Retinoblastoma in adults: a case report and literature review

Purpose:

To report a case of adult retinoblastoma with a wrong diagnosis of melanoma.

Case report:

Herein, we present an adult retinoblastoma case who was misdiagnosed as melanoma in fine-needle aspiration biopsy with intravitreal hemorrhage and later neovascular glaucoma after biopsy. The diagnosis of retinoblastoma was confirmed after enucleation.

Conclusion:

Retinoblastoma should be considered in the differential diagnosis of an intraocular mass in adults, especially when media haziness precludes adequate ophthalmoscopic visualization.

Destruction of the craniofacial skeleton in the child caused by an orbital tumor

PURPOSE

The aims of this paper are to describe the morphological alterations within an infant craniofacial skeleton caused by an orbital tumor and present how the bone reacts in contact with a spreading tumor mass.

METHODS

A study was performed on the dry skull of a child at the age of approximately 2 years. Morphological alterations of the craniofacial skeleton were analysed by visual inspection, and the intracranial cavity was examined with the aid of a digital camera. Subsequently, the skull was examined using computed tomography.

RESULTS

The skull was identified as having unilateral symptoms of orbital destruction caused by a malignant tumor, probably retinoblastoma or rhabdomyosarcoma. The left orbit and surrounding bones showed extensive malformation caused by the invading tumor. Profound deformities were also observed in the nasal cavity, which was partially occluded by the collapsed medial wall of the left orbit. The tumor extended to the wall of the orbit, spread out of the orbit, penetrated to the anterior cranial fossa, and probably invaded the brain.

CONCLUSIONS

Extensive pathological cranial destruction and possible metastases to inner organs suggest that the orbital tumor was the cause of death. Anatomical alterations observed in the craniofacial skeleton indicate a highly aggressive character of the orbital tumor.

Resistant retinoblastoma in a 23-year-old patient

Retinoblastoma is a very rare disease in adults. We are reporting a rare case of resistant retinoblastoma in 23-year-old patient. A 23-year-old male patient presented with loss of vision in the right eye over one-month duration. Examination showed an epiretinal membrane in the right macula in addition to a white mass located inferiorly and associated with vitreous seeds. The diagnosis of retinoblastoma was established. In order to save the patient's life and to preserve the eye and vision, he was treated with chemotherapy, focal therapy, and radioactive Iodine¹²⁵ plaque therapy. The tumor was resistant for treatment and recurred two years after plaque therapy, and enucleation showed well-differentiated retinoblastoma. Retinoblastoma may present in adults, and it was resistant to both chemotherapy and plaque radiation therapy in our case.

Failure of globe conservation in a case of adult onset retinoblastoma

Adult onset retinoblastoma is a rare intraocular malignancy. The majority of the cases are treated with enucleation, due to late presentation and advanced-stage tumors. Here we report a case of a 30-year-old female who presented with an intraocular mass with exudative retinal detachment in her right eye. B-scan ultrasound and magnetic resonance imaging (MRI) confirmed the diagnosis of retinoblastoma. In an attempt to salvage the globe, she was treated with chemotherapy, which resulted in excellent regression of the tumor mass by the end of 8 months follow-up. The patient was followed-up regularly with focal treatment whenever necessary. Two years later, she developed a massive recurrence necessitating enucleation. Histopathologic examination revealed a moderately differentiated retinoblastoma with choroidal invasion. Attempt to salvage the globe in adult onset retinoblastoma with chemoreduction and focal therapy may be possible; however, regular long-term follow-up is necessary for recurrence which warrants timely intervention.

Orbital retinoblastoma in an adult

PURPOSE

Retinoblastoma is usually seen in children before 5 years of age. We report an unusual case of retinoblastoma in an adult who presented to us with an orbital mass.

METHODS

A 24 year-old-male presented to our centre with a history of protrusion of the right eye for 6 months, and associated loss of vision. Ultrasonography B-scan revealed an intraocular mass with calcification and MRI of the orbits showed extra-ocular spread. An incisional biopsy was taken from the orbital mass.

RESULTS

On biopsy, histopathologic features and immunohistochemical stains were consistent with retinoblastoma.

CONCLUSION

To our knowledge, this is the first report of retinoblastoma presenting as an orbital mass in adulthood and highlights the importance of considering this tumour in the differential diagnosis of an intraocular mass with orbital extension in an adult patient.

Retinoblastoma in a 48-year-old woman

PURPOSE

The purpose of this study was to describe an unusual presentation of retinoblastoma in an adult.

METHODS

Retrospective case report.

RESULTS

A 48-year-old woman with floaters was found to have an amelanotic intraocular mass with localized vitreous seeds in the superior fundus. Metastatic workup was negative. Cytologic examination of the vitrectomy specimen showed a malignant neoplasm with neuroendocrine differentiation, suspicious for carcinoid tumor. The patient later was found to have a lung lesion presumed to be a carcinoid tumor. She was treated with external beam radiation to the eye, but 1 year later, a new retinal tumor was discovered inferiorly requiring plaque radiotherapy. Soon thereafter, she developed massive intraocular recurrence. The eye was enucleated. Histopathology revealed small round blue cells with round hyperchromatic nuclei. Rosettes were also present within the tumor consistent with retinoblastoma.

CONCLUSION

Late-onset retinoblastoma can occur in adults, and the diagnosis can be challenging.

Presentation of retinoblastoma in pregnancy

A 22-year-old female in her third trimester of pregnancy was referred to our department for sudden loss of vision with a painful blind eye. It was diagnosed as retinoblastoma clinically and radiologically. Histopathology and immunohistochemistry confirmed the diagnosis. This case is one of its kind because retinoblastoma occurring during pregnancy had not been reported in literature so far.

Cytopathological diagnosis of adult retinoblastoma in a vitrectomy specimen

Retinoblastoma (RB) is extremely rare in adults. We describe a case of RB diagnosed by cytology in a vitrectomy specimen of a 23-year-old patient who presented with diminished visual acuity and retinal detachment in the absence of a clinically-visible mass. Cytological examination of the vitreous fluid showed clusters of loosely cohesive atypical cells with high nuclear to cytoplasmic ratio and "salt and pepper" chromatin pattern in a background of normal neuronal retinal cells. Nuclear molding was present as well as numerous apoptotic bodies. The cells were focally positive for epithelial markers and showed strong and diffuse positivity for neuroendocrine markers. Ki-67 stained 90% of the "atypical cells" nuclei, in contrast to nonneoplastic retinal neuronal cells, which were negative for the marker. A diagnosis of RB was rendered, and subsequently was confirmed in the enucleation specimen. The cytological differential diagnosis is discussed as well as the role that cytology and immunohistochemistry can play in differentiating neoplastic cells from normal retinal cellular elements in vitreous fluid specimens.

Retinoblastoma

Retinoblastoma (Rb) is a malignant tumor that originates from developing retina. Diagnosis based on clinical signs and symptoms and is usually made in children under the age of five years. Mutations in both alleles of the RB1 gene are a prerequisite for this tumor to develop. In most patients with sporadic unilateral Rb, both RB1 gene mutations occur in somatic cells and are not passed over to offspring (nonhereditary Rb). Almost all patients with sporadic bilateral and virtually all patients with familial Rb are heterozygous for RB1 gene mutations that cause predisposition to Rb (hereditary Rb). In families, Rb predisposition is transmitted as an autosomal dominant trait (familial Rb). In addition to Rb, patients with hereditary disease also have an increased risk of tumors outside the eye (second cancer). This risk is enhanced in patients who have received external beam radiotherapy. Analysis of genotype-phenotype associations has shown that the mean number of tumor foci that develop in carriers of mutant RB1 alleles is variable depending on which functions of the normal allele are retained and to what extent. Moreover, phenotypic expression of hereditary retinoblastoma is subject to genetic modification. Identification of the genetic factors that underlie these effects will not only help to arrive at a more precise prognosis but may also point to mechanisms that can be used to reduce the risk of tumor development.

The relationship between tumor cell differentiation and age at diagnosis in retinoblastoma

PURPOSE

To determine the relationship between tumor cell differentiation and age at diagnosis in retinoblastoma.

METHODS

Medical records of 170 patients with retinoblastoma treated by enucleation were reviewed retrospectively. Age at diagnosis and histopathological features were analyzed.

RESULTS

Well-differentiated tumors presented earlier than poorly differentiated tumors. The frequency of presentation was highest in the first year of age for well-differentiated tumors and in the third year of age for poorly differentiated tumors (P < .0001). Bilateral well-differentiated tumors presented earlier than bilateral poorly differentiated tumors. Similarly, unilateral well-differentiated tumors presented earlier than unilateral poorly differentiated tumors.

CONCLUSIONS

Differentiated tumors present earlier than poorly differentiated tumors, irrespective of laterality in retinoblastoma.