Late diagnosis of retinoblastoma in a developing country

Role of long non-coding RNA ELFN1-AS1 in carcinogenesis

As one of the leading causes of death worldwide, cancer significantly burdens patients and the healthcare system. The role of long non-protein coding RNAs (lncRNAs) in carcinogenesis has been extensively studied. The lncRNA ELFN1-AS1 was discovered recently, and subsequent studies have revealed its aberrantly high expression in various cancer tissues. In vitro and in vivo experiments have consistently demonstrated the close association between increased ELFN1-AS1 expression and malignant tumor characteristics, particularly in gastrointestinal malignancies. Functional assays have further revealed the mechanistic role of ELFN1-AS1 as a competitive endogenous RNA for microRNAs, inducing tumor growth, invasive features, and drug resistance. Additionally, the investigation into the clinical implication of ELFN1-AS1 has demonstrated its potential as a diagnostic, therapeutic, and, notably, prognostic marker. This review provides a comprehensive summary of evidence regarding the involvement of ELFN1-AS1 in cancer initiation and development, highlighting its clinical significance.

Update on chemotherapy modalities for retinoblastoma: Progress and challenges

Retinoblastoma stands as a paradigm of success in treating malignancies among pediatric patients. Over recent decades, the approach to managing retinoblastoma has evolved significantly, transitioning from the preservation of patients' lives to the preservation of eyes and vision while minimizing treatment-related complications. Chemotherapy, administered through diverse routes, has solidified its role as the cornerstone of retinoblastoma treatment. In addition to intravenous chemotherapy (IVC), alternative administration routes, including intraarterial (IAC), intravitreal, intracameral, and periocular delivery, have emerged as promising modalities for retinoblastoma management. Numerous studies have demonstrated outstanding outcomes, achieving nearly 100% salvage rates for eyes classified under groups A-C. However, for advanced intraocular retinoblastoma (groups D and E eyes), IAC appears to offer superior local control rates compared to IVC. Intravitreal injection of chemotherapeutic agents, when administered in a controlled and secure manner, holds promise in averting the need for enucleation and radiotherapy in advanced retinoblastoma cases presenting with vitreous seeds. The optimal chemotherapy strategy remains meticulously tailored based on numerous factors. This review provides a comprehensive update on chemotherapy across various routes, encompassing key considerations, dosages, administration methods, treatment outcomes, and potential complications. Furthermore, it explores emerging potential treatments and outlines future directions aimed at enhancing treatment outcomes.

From diagnosis to therapy: The transformative role of lncRNAs in eye cancer management

The genomic era has brought about a transformative shift in our comprehension of cancer, unveiling the intricate molecular landscape underlying disease development. Eye cancers (ECs), encompassing diverse malignancies affecting ocular tissues, pose distinctive challenges in diagnosis and management. Long non-coding RNAs (lncRNAs), an emerging category of non-coding RNAs, are pivotal actors in the genomic intricacies of eye cancers. LncRNAs have garnered recognition for their multifaceted roles in gene expression regulation and influence on many cellular processes. Many studies support that the lncRNAs have a role in developing various cancers. Recent investigations have pinpointed specific lncRNAs associated with ECs, including retinoblastoma and uveal melanoma. These lncRNAs exert control over critical pathways governing tumor initiation, progression, and metastasis, endowing them with the ability to function as evaluation, predictive, and therapeutic indicators. The article aims to synthesize the existing information concerning the functions of lncRNAs in ECs, elucidating their regulatory mechanisms and clinical significance. By delving into the lncRNAs' expanding relevance in the modulation of oncogenic and tumor-suppressive networks, we gain a deeper understanding of the molecular complexities intrinsic to these diseases. In our exploration of the genomic intricacies of ECs, lncRNAs introduce a fresh perspective, providing an opportunity to function as clinical and therapeutic indicators, and they also have therapeutic benefits that show promise for advancing the treatment of ECs. This comprehensive review bridges the intricate relationship between lncRNAs and ECs within the context of the genomic era.

Single-cell transcriptomics enable the characterization of local extension in retinoblastoma

Retinoblastoma (RB) is the most prevalent ocular tumor of childhood, and its extraocular invasion significantly increases the risk of metastasis. Nevertheless, a single-cell characterization of RB local extension has been lacking. Here, we perform single-cell RNA sequencing on four RB samples (two from intraocular and two from extraocular RB patients), and integrate public datasets of five normal retina samples, four intraocular samples, and three extraocular RB samples to characterize RB local extension at the single-cell level. A total of 128,454 qualified cells are obtained in nine major cell types. Copy number variation inference reveals chromosome 6p amplification in cells derived from extraocular RB samples. In cellular heterogeneity analysis, we identified 10, 8, and 7 cell subpopulations in cone precursor like cells, retinoma like cells, and MKI67+ photoreceptorness decreased (MKI67+ PhrD) cells, respectively. A high expression level of SOX4 was detected in cells from extraocular samples, especially in MKI67+ PhrD cells, which was verified in additional clinical RB samples. These results suggest that SOX4 might drive RB local extension. Our study presents a single-cell transcriptomic landscape of intraocular and extraocular RB samples, improving our understanding of RB local extension at the single-cell resolution and providing potential therapeutic targets for RB patients.

CTSB Nuclear Translocation Facilitates DNA Damage and Lysosomal Stress to Promote Retinoblastoma Cell Death

Retinoblastoma (RB) is a pernicious tumor originating from photoreceptor precursor cells that often endangers the lives of children. The purpose of our study was to further investigate the influence of cathepsin B (CTSB) nuclear translocation on RB cell death. Y79 cells were injected into the vitreous cavity of nude mice at a dose of 4 µL/mouse to establish an animal model of RB. Real-time quantitative polymerase chain reaction (RT-qPCR), Western blot analysis, a comet assay, a Cell Counting Kit-8 (CCK-8) assay and flow cytometry were used to measure the levels of the interrelated genes and proteins and to evaluate alterations in autophagy, apoptosis, proliferation, DNA damage and cell cycle arrest. CTSB was found to be expressed at low levels in RB animal model samples and RB cell lines. Functionally, CTSB nuclear translocation promoted DNA damage, cell cycle arrest, ferroptosis and autophagy in Y79 cells and inhibited their proliferation. Downstream mechanistic studies showed that nuclear translocation of CTSB facilitates DNA damage and cell cycle arrest in RB cells by inhibiting breast cancer 1 protein (BRCA1) expression and also activates the signal transducer and activator of transcription 3/stimulator of interferon response cGAMP interactor 1 (STAT3/STING1) pathway to induce lysosomal stress, leading to ferroptosis and autophagy in Y79 cells and alleviating RB. Nuclear translocation of CTSB facilitates DNA damage and cell cycle arrest in RB cells by inhibiting BRCA1 expression and activating the STAT3/STING1 pathway and induces lysosomal stress, which eventually leads to ferroptosis and autophagy and mitigates RB.

The Most-Cited Articles on Retinoblastoma: A Fifty-Year Perspective

PURPOSE

To summarize the characteristics and trends of interest in retinoblastoma (Rb) in the last 50 years.

METHODS

The Web of Science Database was used to find all studies focused on Rb published from 1970 to 2018. The term "retinoblastoma" was used to search for the 100 most cited records.

RESULTS

The mean number of citations was 153.55 ± 88.9. The majority were from the United States (US) (n = 68). Drs. Shields authored 38% of the papers. The number of citations per year was positively correlated with the number of authors, r = 0.26 (p = 0.008). The number of patients was significantly associated with the number of citations per year (p = 0.012). Although papers on radiotherapy were the most common, publications about intra-arterial chemotherapy (IAC) were associated with 88.3% more citations per year (p = 0.031) and papers on intravenous chemotherapy (IVC) were associated with 40.3% more citations per year (p= 0.04). Review and meta-analysis studies had a higher median of citations (10.5) than interventional (6.4) or observational (5.2) studies.

CONCLUSIONS

This study compiles a comprehensive analysis of the most-cited articles on Rb. Studies with a higher number of citations per year were associated with IAC, which emphasizes the significance of the advances in Rb treatments that allow for the saving of eyes and vision as well as lives. Review studies had more citations than observational or interventional studies. More citations were associated with a larger number of authors or more reported patients per paper. These findings highlight the importance of collaborations to achieve relevant, high-quality research of Rb.

Determinants of delayed childhood cancer care in low- and middle-income countries: A systematic review

Early access to care is essential to improve survival rates for childhood cancer. This study evaluates the determinants of delays in childhood cancer care in low- and middle-income countries (LMICs) through a systematic review of the literature. We proposed a novel Three-Delay framework specific to childhood cancer in LMICs by summarizing 43 determinants and 24 risk factors of delayed cancer care from 95 studies. Traditional medicine, household income, lack of transportation, rural population, parental education, and travel distance influenced most domains of our framework. Our novel framework can be used as a policy tool toward improving cancer care and outcomes for children in LMICs.

Sensitivity and Specificity of Whole-body MRI for the Detection of Pediatric Malignancy

Children with cancer often present with general and nonspecific symptoms leading to initial diagnostic workup inclusive of clinical imaging. Various sequences of magnetic resonance imaging (MRI) are becoming more available for diagnostic imaging. However, there is currently a dearth of literature quantifying the sensitivity and specificity of whole-body MRI in identifying pediatric malignancy. In this study, a retrospective analysis was performed of pediatric whole-body MRI inclusive of short tau inversion recovery sequence conducted at an academic pediatric medical center from 2013 to 2018. Kappa statistics were used to evaluate the diagnostic agreement between MRI results and the gold standard diagnostic study of the respective final diagnosis. Sensitivity, specificity, false-positive, and false-negative estimates were provided with joint 90% confidence regions. One hundred forty-two patients received a whole-body MRI during the study period. The sensitivity of whole-body MRI in detecting malignancy was found to be 93.8% with a specificity of 93.4%. The positive and negative predictive values were determined to be 65.2% and 99.1%, respectively. Our findings suggest that whole-body MRI may be of value as an initial diagnostic tool for pediatric malignancy. Larger multicenter collaboration will be needed to further support these data.

Nanotechnology for Pediatric Retinoblastoma Therapy

Retinoblastoma is a rare, sometimes hereditary, pediatric cancer. In high-income countries this disease has a survival rate approaching 100%, while in low- and middle-income countries the prognosis is fatal for about 80% of cases. Depending on the stage of the disease, different therapeutic protocols are applied. In more advanced forms of the disease, surgical removal of the entire globe and its intraocular contents (enucleation) is, unfortunately, necessary, whereas in other cases, conventional chemotherapy is normally used. To overcome the side-effects and reduced efficacy of traditional chemotherapic drugs, nanodelivery systems that ensure a sustained drug release and manage to reach the target site have more recently been developed. This review takes into account the current use and advances of nanomedicine in the treatment of retinoblastoma and discusses nanoparticulate formulations that contain conventional drugs and natural products. In addition, future developments in retinoblastoma treatment are discussed.

Improving Medical Students’ Awareness About Retinoblastoma: A Practical Strategy

Background

Eye salvage and survival for patients with retinoblastoma (RB) can be improved by enhancement of early diagnosis. This study aims to investigate the impact of modifying the teaching curriculum for medical students about awareness of this condition.

Methods

Medical students completed a questionnaire about RB, preluded by a photograph of a child with leukocoria. Participants were divided into group A (138 participants) and group B (151 participants) who are medical students who have completed the ophthalmology rotation before and after implementing modifications on teaching curriculum that focuses on the red flags of RB consecutively.

Results

Most participants considered leukocoria an abnormal sign. Group A had significantly lower knowledge about diagnosis for RB (P=0.0001). Participants scored higher in group B for the critical questions, such as knowing that RB is a fatal disease (P=0.041) that needs urgent treatment (P=0.042). Only three (2%) students adopted the “watch and wait” strategy in group B, compared to 16 (12%) in group A (P=0.0013). Overall, proficiency score (≥90%) was achieved by 12 (8%) students in group B, but only three (2%) students in group A. Only 41 (27%) students in group B, compared to 90 (65%) students in group A, failed to obtain a sufficiency score (≥70%) in the questionnaire.

Conclusion

Modifying the teaching curriculum of the ophthalmology rotation with an intensified focus on awareness of the life-threatening condition retinoblastoma improved medical students’ knowledge of this malignancy. This intervention is one of the modalities that can lead to a reduction in diagnosis and referral delays and improvement in outcome and survival.

The time to diagnosis and survival in children with solid tumors and lymphoma: results from a single center in Turkey

The longer diagnostic intervals in low- and middle-income countries have been proposed among the possible causes of poorer outcomes in children with cancer. In this single-center study from Turkey, the diagnostic intervals and survival status of 138 children with solid tumors and lymphoma (excluding leukemia) were prospectively evaluated. The median total interval (from the beginning of the first cancer-related symptom to the first day of the cancer-specific therapy), the median patient interval (the time interval from the notification of the first cancer-related symptom to the first admission to a healthcare facility), and the median physician interval (the time interval between the first healthcare admission to the first pediatric oncology visit) were 65, 26, and 24 days, respectively. The estimated 5-year overall survival and event-free survival rates were 80.7% and 69.1%, respectively. The longer time intervals were correlated with age, paternal education, localization, and tumor type. Interestingly, none of the time parameters were found to be associated with survival on regression analysis. In conclusion, the diagnostic delay in children with cancer is multifactorial, and the patient- and disease-related factors are as important as the time intervals on survival.Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2021.1951903.

The Effects of Breastfeeding on Retinoblastoma Development: Results from an International Multicenter Retinoblastoma Survey

The protective effects of breastfeeding on various childhood malignancies have been established but an association has not yet been determined for retinoblastoma (RB). We aimed to further investigate the role of breastfeeding in the severity of nonhereditary RB development, assessing relationship to (1) age at diagnosis, (2) ocular prognosis, measured by International Intraocular RB Classification (IIRC) or Intraocular Classification of RB (ICRB) group and success of eye salvage, and (3) extraocular involvement. Analyses were performed on a global dataset subgroup of 344 RB patients whose legal guardian(s) consented to answer a neonatal questionnaire. Patients with undetermined or mixed feeding history, family history of RB, or sporadic bilateral RB were excluded. There was no statistically significant difference between breastfed and formula-fed groups in (1) age at diagnosis (p = 0.20), (2) ocular prognosis measures of IIRC/ICRB group (p = 0.62) and success of eye salvage (p = 0.16), or (3) extraocular involvement shown by International Retinoblastoma Staging System (IRSS) at presentation (p = 0.74), lymph node involvement (p = 0.20), and distant metastases (p = 0.37). This study suggests that breastfeeding neither impacts the sporadic development nor is associated with a decrease in the severity of nonhereditary RB as measured by age at diagnosis, stage of disease, ocular prognosis, and extraocular spread. A further exploration into the impact of diet on children who develop RB is warranted.

Clinicopathologic Features of Childhood Rhabdomyosarcoma and Treatment Outcomes in Ibadan, Nigeria: A 10-year Review

The objectives of this study were to describe the clinicopathologic features and treatment outcomes of childhood rhabdomyosarcoma in a resource-constrained setting. All cases of childhood rhabdomyosarcoma seen over a 10-year period (July 2006 to June 2016) at the University College Hospital, Ibadan, Nigeria were reviewed. Data were extracted from the database of the pediatric Hematology/Oncology Unit of the hospital and analyzed. Ethical approval was obtained from the Institutional Ethics Committee. Fifty children were seen comprising 30 men and 20 women with bimodal ages of 4 and 5 years. Median duration of illness was 16 weeks and the most common primary tumor site was the head-and-neck region in 27 (54%) of cases. The histologic subtypes were embryonal in 30 (60%), alveolar in 9 (18%), and not specified in 11 (22%). The Intergroup Rhabdomyosarcoma Study group TNM Pretreatment stages were stage I in 15 (30%), stage III in 17 (34%), and stage IV in 18 (36%). Treatment included chemotherapy, surgery, and radiotherapy and abandoned in 20 (40%) cases. Median survival was 45 weeks (95% confidence interval: 16.4-73.6) and 5 (10%) patients were alive and disease free, 4 years or more after diagnosis. Outcome of childhood rhabdomyosarcoma is poor and early diagnosis and improved access to treatment are recommended.

Socioeconomic status and retinoblastoma survival: Experience of a tertiary cancer center in Brazil

BACKGROUND

Little is known about socioeconomic status (SES) and its effects in childhood cancer survival. This study aims to discuss the association between SES and survival of patients with retinoblastoma (RB) from a tertiary treatment center.

PROCEDURE

A retrospective cohort study was conducted, including all patients with RB referred to the Brazilian National Institute of Cancer in Rio de Janeiro (January 2000-December 2016).

RESULTS

Data from 160 patients were analyzed with mean age at diagnosis of 22.85 months (SD ± 14.29). Eighty-three patients (51.9%) had an interval to diagnosis equal to or longer than six months, and 13 children (8.1%) abandoned treatment. Five-year overall survival rate for all patients was 78.8% (95% CI, 72.4%-85.9%). In a multivariate model, patients whose fathers had more than nine years of study had a lower death risk. Patients from families having more than one child under five years had a 213% higher risk of death compared with those living with no other small child. Treatment abandonment also had a profound effect on death risk.

CONCLUSION

Childhood cancer is notably important considering the potential years of life lost. RB has even more important elements, as the possibility of vision loss in cases with delayed diagnosis. Family characteristics seem to be highly related to RB survival, especially in low- and middle-income countries, where inequalities are still a public health issue. Strategies to improve survival should focus not only on large-scale settings such as improving national healthcare systems but also on more personalized actions that might help to mitigate disparities.

Modern treatment of retinoblastoma: A 2020 review

Retinoblastoma management remains complex, requiring individualized treatment based on International Classification of Retinoblastoma (ICRB) staging, germline mutation status, family psychosocial factors and cultural beliefs, and available institutional resources. For this 2020 retinoblastoma review, PubMed was searched for articles dated as early as 1931, with an emphasis on articles from 1990 to the present day, using keywords of retinoblastoma, chemotherapy, intravenous chemotherapy, chemoreduction, intra-arterial chemotherapy, ophthalmic artery chemosurgery, intravitreal chemotherapy, intracameral chemotherapy, cryotherapy, transpupillary thermotherapy, laser, radiation, external beam radiotherapy, plaque radiotherapy, brachytherapy, and enucleation. We discuss current treatment modalities as used in the year 2020, including intravenous chemotherapy (IVC), intra-arterial chemotherapy (IAC), intravitreal chemotherapy (IvitC), intracameral chemotherapy (IcamC), consolidation therapies (cryotherapy and transpupillary thermotherapy [TTT]), radiation-based therapies (external beam radiotherapy [EBRT] and plaque radiotherapy), and enucleation. Additionally, we present a consensus treatment algorithm based on the agreement of three North American retinoblastoma treatment centers, and encourage further collaboration amongst the world's most expert retinoblastoma treatment centers in order to develop consensus management plans and continue advancement in the identification and treatment of this childhood cancer.

Travel burden and clinical presentation of retinoblastoma: analysis of 1024 patients from 43 African countries and 518 patients from 40 European countries

BACKGROUND

The travel distance from home to a treatment centre, which may impact the stage at diagnosis, has not been investigated for retinoblastoma, the most common childhood eye cancer. We aimed to investigate the travel burden and its impact on clinical presentation in a large sample of patients with retinoblastoma from Africa and Europe.

METHODS

A cross-sectional analysis including 518 treatment-naïve patients with retinoblastoma residing in 40 European countries and 1024 treatment-naïve patients with retinoblastoma residing in 43 African countries.

RESULTS

Capture rate was 42.2% of expected patients from Africa and 108.8% from Europe. African patients were older (95% CI -12.4 to -5.4, p<0.001), had fewer cases of familial retinoblastoma (95% CI 2.0 to 5.3, p<0.001) and presented with more advanced disease (95% CI 6.0 to 9.8, p<0.001); 43.4% and 15.4% of Africans had extraocular retinoblastoma and distant metastasis at the time of diagnosis, respectively, compared to 2.9% and 1.0% of the Europeans. To reach a retinoblastoma centre, European patients travelled 421.8 km compared to Africans who travelled 185.7 km (p<0.001). On regression analysis, lower-national income level, African residence and older age (p<0.001), but not travel distance (p=0.19), were risk factors for advanced disease.

CONCLUSIONS

Fewer than half the expected number of patients with retinoblastoma presented to African referral centres in 2017, suggesting poor awareness or other barriers to access. Despite the relatively shorter distance travelled by African patients, they presented with later-stage disease. Health education about retinoblastoma is needed for carers and health workers in Africa in order to increase capture rate and promote early referral.

Epidemiological profile of retinoblastoma in North India: Implications for primary care and family physicians

Background:

Retinoblastoma is the most common primary intraocular malignancy among children. Despite being curable in early stages, majority of the cases in India present in late stages, when outcomes are very poor.

Objectives:

The aim of this study was to assess the epidemiological profile, clinical characteristics, and treatment practices among retinoblastoma patients in north India.

Materials and Methods:

Data on all patients with retinoblastoma, over a 10-year-time period from 2009 to 2018, who were treated in a tertiary care hospital in north India, were assessed. Data were analyzed to describe the demographic characteristics, clinical features in terms of stage at presentation, and management practices in terms of diagnostic investigations and treatment. The statistical significance for difference in percentages was assessed using Fischer's exact test at a 5% significance level.

Results:

A total of 25 retinoblastoma patients were enlisted, of whom one was excluded as it was adult onset retinoblastoma. The median age at presentation was 3 years, with a male to female ratio of 1:1.4. Bilateral presentation was seen in 16.6% cases. Majority (66.6%) of the patients underwent magnetic resonance imaging of brain and orbit as a part of the diagnostic workup. Intraocular disease was seen in 58.3% patients, whereas 41.6% patients had extraocular disease. Local therapy with vision preservation could be used only in 8.3% patients, whereas 87.5% patients were referred for enucleation. Chemotherapy with combination of vincristine, etoposide, and carboplatin was used extensively both, in neoadjuvant setting (83.3%) and in the adjuvant setting.

Conclusion:

Despite availability of treatment for eye preservation, its utility is limited due to the advanced stage at presentation. Awareness about the disease and its symptoms for early diagnosis, especially with the Mid-Level Health Provider at Health and Wellness Centers, is likely to improve early reporting and treatment and meeting the Vision 2020 goals.

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives

To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants

A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

Determinants of delayed diagnosis among pediatric cancer patients from Ayder Comprehensive Specialized Hospital, Mekelle, Northern Ethiopia

Background

Despite advances in the field of pediatric oncology, cancer remains a leading cause of death in children. The delays in cancer diagnosis may occur throughout the diagnostic pathway. Diagnosis of childhood cancer as early as possible is crucial to reduce mortality. The aim of this study was to identify determinants of delayed diagnosis among pediatric cancer patients in Ayder Comprehensive Specialized Hospital, Northern Ethiopia.

Method

Facility based cross-sectional study was conducted among pediatric cancer patients aged less than 18 years. Data collection was done by interviewer-administered structured questionnaire from the volunteer primary caregiver from 1st September 2017 to 30th August 2018. The data was checked and cleaned by principal investigator on daily basis during data collection for completeness, consistencies, then coded, entered and analyzed using SPSS version 21 software. Diagnosis delay was considered significant when it is above the 3rd quartile. Binary logistic regression analysis was used to test associations between each of the determinant factors and the dependent variable. Variables with P-value < 0.25 during bivariate analysis were fed to the multivariate logistic regression model. Finally, variables with P-value < 0.05 were considered as determinants of delayed diagnosis.

Results

From a total of 102 patients, 71(69.6%) had delayed diagnosis. Children older than 10 years of age were four (AOR = 4.01; 95%CI = 1.55–12, P < 0.001) times more likely to get delayed compared to under five children. Rural residence (AOR = 3.3; 95%CI = 1.24–10.24, P < 0.001), uneducated parents (AOR = 3.4; 95%CI = 1.91–13.25, P = 0.009), parents with monthly income less than 1000 ETB (AOR = 6.1; 95%CI = 1.76–7.23, P < 0.001), absence of health insurance (AOR = 2.4; 95%CI = 1.50–3.50, P = 0.02), visit to holy water (AOR = 3.4;95%CI = 1.6–7.2) and those who think cancer is incurable (AOR = 2.7;95%CI = 1.3–14,P = 0.004) were also likely to be delayed.

Conclusion

Delayed diagnosis of childhood cancer was a major issue and most influenced by the child’s age, residency, family’s socioeconomic status, parental education, health insurance, use of holy water and caregivers perception on curability of cancer. Thus; every effort should be made to promote public and parental awareness of childhood cancer and promoting health insurance.

Racial, Ethnic, and Socioeconomic Disparities in Retinoblastoma Enucleation: A Population-Based Study, SEER 18 2000-2014

PURPOSE

To determine the effect of race, ethnicity, and census tract-level composite socioeconomic status (SES) on retinoblastoma enucleation. This study augments Truong and associates, providing multivariate analyses combining sociodemographic and clinical characteristics with more accurate SES measures. We hypothesized that children from nonwhite, Hispanic, and lower socioeconomic backgrounds would have increased adjusted odds of enucleation.

DESIGN

Retrospective cohort analysis.

SETTING

Multicenter population-based study using the Surveillance, Epidemiology, and End Results (SEER) 18 Registries.

STUDY POPULATION

Children aged 18 years and younger diagnosed with retinoblastoma between 2000 and 2014. Subjects were identified using International Classification of Diseases-Oncology (ICD-O) site and morphology codes.

MAIN OUTCOME MEASURES

Enucleation odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Analysis of 959 retinoblastoma patients revealed that 70.8% were enucleated. Adjusted analyses showed associations between enucleation and Asian (OR 2.00, CI 1.08-3.71) or black (2.42, 1.41-4.16) race, Hispanic ethnicity (1.69, 1.16-2.46), and low SES (1.68, 1.09-2.58). Significantly increased enucleation risk was associated with older age at diagnosis (age 1-2 years 2.55, 1.80-3.61; >2 years 4.88, 2.57-9.25), unilateral disease (5.00, 3.45-7.14), and advanced stage (regional 4.71, 2.51-8.84; distant 3.15, 1.63-6.08). No interactions were observed between race, ethnicity, SES, and stage at diagnosis. Enucleation rates decreased over time across all racial, ethnic, and socioeconomic groups.

CONCLUSIONS

Children from nonwhite, Hispanic, and lower socioeconomic backgrounds are more likely to receive enucleation. These associations are independent of stage of diagnosis, suggesting larger systemic disparities in retinoblastoma care. The origin of these differences requires further study and attention by clinicians and policy makers.

Establishment of a formal program for retinoblastoma: Feasibility of clinical coordination across borders and impact on outcome

Retinoblastoma is an ocular tumor that occurs in young children, in either heritable or sporadic manner. The relative rarity of retinoblastoma, and the need for expensive equipment, anesthesia, and pediatric ophthalmologic expertise, are barriers for effective treatment in developing countries. Also, with an average age-adjusted incidence of two to five cases per million children, patient number limits development of local expertise in countries with small populations. Lebanon is a small country with a population of approximately 4.5 million. In 2012, a comprehensive retinoblastoma program was formalized at the Children's Cancer Institute (CCI) at the American University of Beirut Medical Center, and resources were allocated for efficient interdisciplinary coordination to attract patients from neighboring countries such as Syria and Iraq, where such specialized therapy is also lacking. Through this program, care was coordinated across hospitals and borders such that patients would receive scheduled chemotherapy at their institution, and monthly retinal examinations and focal laser therapy at the CCI in Lebanon. Our results show the feasibility of successful collaboration across borders, with excellent patient and physician adherence to treatment plans. This was accompanied by an increase in patient referrals, which enables continued expertise development. However, the majority of patients presented with advanced intraocular disease, necessitating enucleation in 90% of eyes in unilateral cases, and more than 50% of eyes in bilateral cases. Future efforts need to focus on expanding the program that reaches to additional hospitals in both countries, and promoting early diagnosis, for further improvement of globe salvage rates.

Delayed Enucleation With Neoadjuvant Chemotherapy in Advanced Intraocular Unilateral Retinoblastoma: AHOPCA II, a Prospective, Multi-Institutional Protocol in Central America

PURPOSE

Treatment abandonment because of enucleation refusal is a limitation of improving outcomes for children with retinoblastoma in countries with limited resources. Furthermore, many children present with buphthalmos and a high risk of globe rupture during enucleation. To address these unique circumstances, the AHOPCA II protocol introduced neoadjuvant chemotherapy with delayed enucleation.

PATIENTS AND METHODS

Patients with advanced unilateral intraocular disease (International Retinoblastoma Staging System [IRSS] stage I) were considered for upfront enucleation. Those with diffuse invasion of the choroid, postlaminar optic nerve, and/or anterior chamber invasion received six cycles of adjuvant chemotherapy (vincristine, carboplatin, and etoposide). Patients with buphthalmos and those with a perceived risk for enucleation refusal and/or abandonment were given two to three cycles of chemotherapy before scheduled enucleation followed by adjuvant chemotherapy to complete six cycles, regardless of pathology.

RESULTS

A total of 161 patients had unilateral IRSS stage I disease; 102 underwent upfront enucleation, and 59 had delayed enucleation. The estimated 5-year abandonment-sensitive event-free and overall survival rates for the group were 0.81 ± 0.03 and 0.86 ± 0.03, respectively. The 5-year estimated abandonment-sensitive event-free survival rates for patients undergoing upfront and delayed enucleation were 0.89 ± 0.03 and 0.68 ± 0.06, respectively (P = .001). Compared with AHOPCA I, abandonment for patients with IRSS stage I retinoblastoma decreased from 16% to 4%.

CONCLUSION

AHOPCA describes the results of advanced intraocular retinoblastoma treated with neoadjuvant chemotherapy. In eyes with buphthalmos and patients with risk of abandonment, neoadjuvant chemotherapy can be effective when followed by enucleation and adjuvant chemotherapy. Our study suggests that this approach can save patients with buphthalmos from ocular rupture and might reduce refusal of enucleation and abandonment.

Associations among Socioeconomic Factors, Lag Time, and High-Risk Histopathologic Features in Eyes Primarily Enucleated for Retinoblastoma

Purpose/Aim: To determine the associations among socioeconomic factors, delay in management, and high-risk histopathologic features in eyes primarily enucleated for retinoblastoma. Materials and Methods: A single-site survey was conducted from January 2016 through January 2018. Eyes primarily enucleated for unilateral retinoblastoma were reviewed for the presence of high-risk histopathologic features. Information on clinical characteristics, socioeconomic factors, and lag time were collected during hospitalization. Results: Of the 138 children analyzed, 60 (43.5%) carried high-risk histopathologic features. Compared to children with a standard risk, those with a high risk had a longer median lag time before treatment (21.5 vs 15.0 days, P = .007), but their overall lag time (54.0 vs 50.0 days, P = .062) and delay in the initial visit (7.0 vs 10.0 days, P = .782) were comparable. Logistic regression analysis showed that children with a lag time ≥ 30 days were at a significantly higher risk of extraocular invasion (odds ratio [OR] = 2.38 and 95% confidence interval [CI] = 1.08-5.37 for treatment delay; OR = 2.12 and 95% CI = 1.01-4.62 for overall delay). Neither high-risk histopathologic features nor lag time was associated with any demographic or major socioeconomic factors, including sex, age at diagnosis or enucleation, ethnicity, household income, parents' education level, medical insurance coverage, and left-behind status. Conclusions: For children with advanced unilateral retinoblastoma, there is no statistical difference in overall lag time between standard and high-risk groups. Major socioeconomic parameters have little impact on the delay and histopathologic outcomes, thus implying that children with varied socioeconomic status may be at a similar risk of advanced tumor invasion.

Baseline characteristics and outcomes of children with cancer in the English-speaking Caribbean: A multinational retrospective cohort

BACKGROUND

English-speaking Caribbean (ESC) childhood cancer outcomes are unknown.

PROCEDURE

Through the SickKids-Caribbean Initiative (SCI), we established a multicenter childhood cancer database across seven centers in six ESC countries. Data managers entered patient demographics, disease, treatment, and outcome data. Data collection commenced in 2013, with retrospective collection to 2011 and subsequent prospective collection.

RESULTS

A total of 367 children were diagnosed between 2011 and 2015 with a median age of 5.7 years (interquartile range 2.9-10.6 years). One hundred thirty (35.4%) patients were diagnosed with leukemia, 30 (8.2%) with lymphoma, and 149 (40.6%) with solid tumors. A relative paucity of children with brain tumors was seen (N = 58, 15.8%). Two-year event-free survival (EFS) for the cohort was 48.5% ± 3.2%; 2-year overall survival (OS) was 55.1% ± 3.1%. Children with acute lymphoblastic leukemia (ALL) and Wilms tumor (WT) experienced better 2-year EFS (62.1% ± 6.4% and 66.7% ± 10.1%), while dismal outcomes were seen in children with acute myeloid leukemia (AML; 22.7 ± 9.6%), rhabdomyosarcoma (21.0% ± 17.0%), and medulloblastoma (21.4% ± 17.8%). Of 108 deaths with known cause, 58 (53.7%) were attributed to disease and 50 (46.3%) to treatment complications. Death within 60 days of diagnosis was relatively common in acute leukemia [13/98 (13.3%) ALL, 8/26 (30.8%) AML]. Despite this, traditional prognosticators adversely impacted outcome in ALL, including higher age, higher white blood cell count, and T-cell lineage.

CONCLUSIONS

ESC childhood cancer outcomes are significantly inferior to high-income country outcomes. Based on these data, interventions for improving supportive care and modifying treatment protocols are under way. Continued data collection will allow evaluation of interventions and ensure maximal outcome improvements.

Retinoblastoma in Sub-Saharan Africa: Case Studies of the Republic of Côte d'Ivoire and the Democratic Republic of the Congo

PURPOSE

In most low-income countries, the diagnosis of retinoblastoma is delayed, resulting in a severe prognosis. The objectives of this study were to describe the access to diagnosis and care of children diagnosed with retinoblastoma and the challenges in two sub-Saharan African countries: the Republic of Côte d'Ivoire and the Democratic Republic of the Congo.

PATIENTS AND METHODS

A descriptive cross-sectional study was conducted. Data were collected from the medical records of patients admitted during the period of January 1, 2013 to December 31, 2014. Data were entered and analyzed using Epi Info7.1 software and SAS 9.3.

RESULTS

One hundred sixteen cases of retinoblastoma were collected, including 60 boys and 56 girls. The median diagnosis age was 3 years for both countries. Ninety-eight patients (84%) had unilateral retinoblastoma. Most of the patients presented with advanced disease (76% had extraocular retinoblastoma). Median time between initial symptoms and diagnosis was 8.5 months (range, 0.4 to 116.7 months). Median time between diagnosis and treatment initiation was 31 days (range, 0 to 751 days). The median cost for the treatment of the disease was estimated at $1,954 per patient.

CONCLUSION

Late diagnosis of retinoblastoma, with extraocular disease, occurs frequently in both African countries. It is associated with delay in initiating treatment, and the cost of the treatment remains unaffordable for most of the families. Support groups for parents of affected children and the support of the Franco-African Pediatric Oncology Group remain important in improving early diagnosis and providing treatment in sub-Saharan African countries.

Treatment of retinoblastoma in Sub-Saharan Africa: Experience of the paediatric oncology unit at Gabriel Toure Teaching Hospital and the Institute of African Tropical Ophthalmology, Bamako, Mali

BACKGROUND

Retinoblastoma (Rb) is the most common intraocular primary malignancy in children. In industrialised countries, the cure rate is about 95%. We present the results of a prospective study on the management of Rb in the paediatric oncology unit of Gabriel Touré Teaching Hospital and African Institute of Tropical Ophthalmology, from November 1, 2011 to December 31, 2015.

PROCEDURE

The aims of this prospective study were to evaluate the treatment of localised Rb, ocular prosthesis after enucleation, conservative management for bilateral Rb as well as survival rates in all patients. Patients with early stage Rb at diagnosis were included. The treatment was performed according to the retinoblastoma treatment guidelines of the French-African Paediatric Oncology Group.

RESULTS

Eighty-eight patients were included in the study. Sex ratio was 1:1 (M = 44, F = 44). Median age at diagnosis was 3 years (range: 2 months-5 years). Unilateral intraocular Rb was predominant (n = 50; 56.8%). Conservative treatments were performed on nine eyes in nine patients. Overall survival and event-free survival of the entire cohort at the end of 4 years were 73% (95% CI 60.8-81.2%) and 59% (95% CI 47.9-69.5%), respectively, with a median follow-up of 3.7 years (0.1-5.6 years). In conclusion, early enucleation in early stage of Rb can improve outcomes in resource-limited countries. Delayed enucleation and refusal of adherence to treatment are still major concerns and remain a barrier to improving overall patient survival.

Factors associated with abandonment of therapy by children diagnosed with solid tumors in Peru

BACKGROUND

Abandonment of treatment is a major cause of treatment failure and poor survival in children with cancer in low- and middle-income countries. The incidence of treatment abandonment in Peru has not been reported. The aim of this study was to examine the prevalence of and factors associated with treatment abandonment by pediatric patients with solid tumors in Peru.

METHODS

We retrospectively reviewed the sociodemographic and clinical data of children referred between January 2012 and December 2014 to the two main tertiary centers for childhood cancer in Peru. The definition of treatment abandonment followed the International Society of Paediatric Oncology, Paediatric Oncology in Developing Countries, Abandonment of Treatment recommendation.

RESULTS

Data from 1135 children diagnosed with malignant solid tumors were analyzed, of which 209 (18.4%) abandoned treatment. Bivariate logistic regression analysis showed significantly higher abandonment rates in children living outside the capital city, Lima (forest; odds ratio [OR] 3.25; P < 0.001), those living in a rural setting (OR 3.44; P < 0.001), and those whose parent(s) lacked formal employment (OR 4.39; P = 0.001). According to cancer diagnosis, children with retinoblastoma were more likely to abandon treatment compared to children with other solid tumors (OR 1.79; P = 0.02). In multivariate regression analyses, rural origin (OR 2.02; P = 0.001) and lack of formal parental employment (OR 2.88; P = 0.001) were independently predictive of abandonment.

CONCLUSION

Treatment abandonment prevalence of solid tumors in Peru is high and closely related to sociodemographical factors. Treatment outcomes could be substantially improved by strategies that help prevent abandonment of therapy based on these results.

Metastatic retinoblastoma of the parotid and submandibular glands: a rare case report

Background

Retinoblastoma is the most common intraocular malignancy occurring in children. It can metastasize to the regional lymph nodes, central nervous system and distant organs usually the bones and bone marrow and very rarely to the soft tissue. Here, we report a case of unilateral retinoblastoma in a 4-year-old girl accompanied by a large metastasis of the parotid and submandibular glands that developed about 6 months previously and gradually increased in size 5 months after enucleation of the left eye.

Case presentation

A 4-year-old girl with a history of unilateral retinoblastoma presented with a large, painful and worsening mass (about 20 × 23 cm) of the left side of the neck. Following surgery, the orbital tumour was completely resected, and the large tumour invasion range in the left side of the neck was not resected completely. Histopathological examination revealed retinoblastoma of the orbit and the parotid and submandibular glands. After chemotherapy and additional local radiotherapy on the parotid and submandibular glands, the tumour was inactive and stable.

Conclusions

Delayed detection and inappropriate management contribute to poor outcomes. Fundus examinations, education regarding the early signs of RB, and optimization of the therapeutic strategy for RB may play important roles in ocular health.

Presenting signs of retinoblastoma at a tertiary level teaching hospital in Ethiopia

Introduction

Retinoblastoma is a primary malignant intraocular neoplasm that arise from immature retinoblasts with in developing retina. The commonest presenting sign in developing country is proptosis which is the late presenting sign. We report presenting signs of retinoblastoma in Ethiopian children seen at a tertiary level teaching hospitals in Ethiopia.

Methods

Prospective case series study was done on children who presented with retinoblastoma between May 1, 2005 and September 1, 2006. This study was done as part of requirement for partial fulfilment of certificate of specialty study in ophthalmology during the year 2005 to 2006. SPSS 11 statistical package was used to analyse the data.

Results

Among 41 patients seen during the study period, 24 (58.5%) were males and 17(41%) were females. Unilateral retinoblastoma was found in 32 (78%) patients and bilateral cases were found in 9(22%). Mean age of onset for right eye was 27.5 months and left eye 33.7 months. The mean ages of presentation at time of diagnosis for right and left eye were 34.4 and 40.2 months, respectively .In bilateral retinoblastoma mean age of presentation was 33.3 months. The commonest presenting sign was proptosis 22(53.7%) followed by leucocorea nine (22%),ocular inflammation four (9.0 %), strabismus three (7.3%), glaucoma one (2.4%), loss of vision one (2.4%)and hyphemaone (2.4%).

Conclusion

The commonest presenting signs of retinoblastoma in our set up were Proptosis followed by leucocorea. This is due to late presentation of patient and late referral by medical professionals. Health education to the public and health professionals will help early detection of retinoblastoma.

Influence of health insurance status on paediatric non-Hodgkin's lymphoma treatment in Kenya

OBJECTIVE

Non-Hodgkin's lymphoma (NHL) is the most common childhood malignancy in sub-Saharan Africa. Survival rates for NHL are higher than 80% in high-income countries.This study explores treatment outcomes of children with NHL in Kenya, a sub-Saharan low-income country, and the association between health insurance status at diagnosis and treatment outcomes.

DESIGN

This was a retrospective medical records study. All children diagnosed with NHL in 2010, 2011 and 2012 were included. Data on treatment outcomes and health insurance status at diagnosis were collected.

RESULTS

Of all 63 patients with NHL, 35% abandoned treatment, 22% had progressive or relapsed disease, 14% died and 29% had event-free survival. Most patients (73%) had no health insurance at diagnosis. Treatment outcomes in children with or without health insurance at diagnosis differed significantly (p=0.005). The most likely treatment outcome in children with health insurance at diagnosis was event-free survival (53%), whereas in children without health insurance at diagnosis it was abandonment of treatment (44%). Crude HR for treatment failure was 3.1 (95% CI 1.41 to 6.60, p=0.005) for uninsured versus insured children. The event-free survival estimate was significantly higher in children with health insurance at diagnosis than in patients without health insurance at diagnosis (p=0.003). Stage of disease at diagnosis was identified as a confounder of this association (adjusted HR=2.4, 95% CI 0.95 to 6.12, p=0.063).

CONCLUSIONS

Survival of children with NHL in Kenya is much lower compared with high-income countries. Abandonment of treatment is the most common cause of treatment failure. Health insurance at diagnosis was associated with better treatment outcomes and survival.

Die Geschichte der Ophthalmoonkologie an der Univ.-Augenklinik Graz

Einleitung

Der Beginn der organerhaltenden Therapie an der Univ.-Augenklinik datiert auf das Jahr 1985 mit der Einführung der Ruthenium 106 Applikatoren (Lommatzsch, Vormun) zurück.

Der Autor skizziert in zeitlicher Abfolge die Einführung und gemeinsame Entwicklung verschiedener Arten von organerhaltender Therapien und endet mit neuen Therapieansätzen des Retinoblastoms und des metastasierenden Aderhautmelanoms.

Methodik

Die Vorstände der Univ.-Augenklinik beginnend mit Hofmann (1964–1987) unterstützten den Paradigmenwechsel von einem radikalchirurgischen Konzept (Enukleation) bei intraokularen Tumoren zu einem organerhaltenden Konzept trotz Fehlens von großen Studien mit hoher Evidenz. Zuweisende FachärztInnen waren zu Recht im Zweifel über die Sinnhaftigkeit dieser neuen Therapiekonzepte, unterstützen jedoch mit ihren PatientInnen Zuweisungen den neuen Arbeitsschwerpunkt bzw. den organerhaltenden Therapieansatz bis zum heutigen Tag.

Ergebnisse

Aderhautmelanom: 1985 wurde die organerhaltende Therapie mittels Ruthenium 106 Applikatoren in Graz für kleine und mittelgroße Aderhautmelanome mit aequatorialler und anteriorer Lokalisation eingeführt, ab 1992 war die Gamma Knife Radiochirurgie alternativ zur Protonen- und Photonentherapie an der Univ. Klinik für Neurochirurgie in Graz verfügbar und wurde mit Beiträgen anderer Tumorzentren für die Behandlung von großen Aderhautmelanomen oder solchen mit posteriorer Lokalisation entwickelt.

Die transpupillare Thermotherapie (TTT) wurde 1995 in Leiden von Osterhuis und Journée-de Korver für die Behandlung von flachen posterior lokalisierten Melanomen im Tiermodell entwickelt. Die Therapie geriet auf Grund einer erhöhten Rate von Rezidiven in einzelnen Tumorzentren in Mißkredit und Vergessenheit, sollte jedoch auf Grund guter eigener Erfahrungen und der Einführung der TTT bei der Behandlung von Retinoblastomen in Hinblick auf Technik und Indikationen neuerlich evaluiert werden.

Endoresektion: Aderhautmelanome werden nach Vorbestrahlung wegen des großen Tumorvolumens bzw. einer persistierenden Amotio mittels Vitrektomie Techniken reserziert, als Bestrahlungstechnik wurde in Graz und in Essen das Gamma Knife verwendet.

Biopsien werden seit einigen Jahren für genetische und mikrobiologische Untersuchungen durchgeführt, neue mikrobiologische Erkenntnisse werden zur Entwicklung neuer systemischer Therapiekonzepte führen.

Retinoblastom: Im Gegensatz zum Aderhautmelanom erwies sich die adjuvante Chemotherapie beim Retinoblastom als hoch wirksam v. a. in der Volumsreduktion der Tumoren.

Die Brachytherapie mit Ruthenium 106 Schalen, die 3‑fach Kryotherapie bzw. die Lasertherapie werden bereits seit Jahrzehnten an der Univ.-Augenklinik als organerhaltende Lokaltherapien durchgeführt, seit kurzem komplettiert die TTT (mit oder ohne simultane Chemotherapie) das Spektrum der fokalen Therapien. Neue Therapiekonzepte wie die intrabulbäre Chemotherapie (bereits in Anwendung) sowie die intraarterielle Chemotherapie (steht kurz vor der Implementierung) sind bereits in Routine.

Seit 2003 werden erstmals Retinoblastome in einer Therapie Optimierungsstudie RBA2003 (die das Department für Hämato‑/Onkologie der Univ. Kinderklinik Graz zusammen mit der Univ.-Augenklinik entwickelt hat) in Graz behandelt. Das Univ. Klinikum Graz etabliert sich als Referenzzentrum für Retinoblastome und Pseudoretinoblastome in Österreich und dem umgebenden Ausland und erhielt Anfragen und PatientInnen Zuweisungen aus den Alpe Adria Ländern sowie Schweiz, Bulgarien, Tschechien, Rumänien, Ukraine und Rußland. Wedrich, derzeitiger Vorstand der Univ.-Augenklinik Graz, förderte die Entwicklung des Retinoblastom Kompetenz Zentrums in personeller, instrumenteller und logistischer Hinsicht.

2015 entwickelte das Klinikum Essen ein auf das Protokoll RBA2003 aufbauendes, erweitertes internationales Protokoll, nach dem nun PatientInnen aus Essen und Graz gemeinsam behandelt, evaluiert und nachkontrolliert werden. Dieses wiederum wird in einem EU-Antrag, initiert von Chandada (Buenos Aires, Barcelona) für eine einheitliche Behandlung des Retinoblastoms in Europa berücksichtigt.

2005 engagierte sich die Arbeitsgruppe erstmals in Mosambique, Afrika folgend einer Bitte der NGO, Licht für die Welt, die Rahmenbedingungen für die Etablierung eines Retinoblastomzentrums zu prüfen.

2008 wurde am LKH Univ. Klinikum Graz ein Forschungsfeld Onkologie etabliert, in weiterer Folge das Comprehensive Cancer Center (CCC) der MUG gegründet, in das die Ophthalmoonkologie thematisch eingegliedert ist.

Schlussfolgerung

Das vor 32 Jahren am LKH Univ.-Klinikum Graz etablierte Konzept der organerhaltenden Therapie erfuhr 13 Jahre später die Bestätigung durch die bislang größte multizentrische Studie (COMS Studie) in den USA, wonach kein Unterschied in Hinblick auf Überleben zwischen Enukleation und bulbuserhaltender Therapie mit Jod 125 Schalen bei kleinen und mittelgroßen Aderhautmelanomen gefunden wurde. Die seit über 30 Jahren unveränderte (z. T. sehr schlechte) Prognose kann möglicherweise in absehbarer Zeit durch neue Medika verbessert werden. Basis für diese erfreulichen Entwicklungen sind neue bahnbrechende Erkenntnisse aus der zytogenetischen und molekularbiologischen Forschung.

An ethnographic exploration of the delivery of psychosocial care to children with cancer in Argentina

PURPOSE

The integration of psychosocial care in the routine care of cancer patients has been set as an international standard, but there are healthcare contexts where these services are lacking as psychosocial care providers are not incorporated in multidisciplinary teams and screening for psychological distress is not carried out routinely or systematically.

METHOD

In this article, we discuss the findings from an ethnographic study that focused on exploring the working experiences of psychosocial care providers from one children's hospital in Buenos Aires, Argentina. The study is based on 10 in-depth interviews with hospital staff members and participant observation in selected hospital areas. The transcripts from the interviews and fieldnotes from the observations were analyzed using thematic analysis.

RESULTS

We found that psychosocial care providers encounter difficulties while attempting to deliver services to children and their families, produced mainly by their lack of collaboration with other professional groups, insufficient human resources, and a growing patient population. As a result of this situation, psychosocial care providers often prioritize some patients over others, leaving a considerable number of patients and family members without psychosocial support.

CONCLUSIONS

The study highlighted the barriers psychosocial care providers encounter while attempting to deliver services to children and their families. Further work needs to be carried out to fully integrate psychosocial care in national health policies and ensure this type of support is available for all patients and their families.

Systematic review of the current status of programs and general knowledge of diagnosis and management of retinoblastoma

BACKGROUND

This systematic review aims to report the current knowledge of retinoblastoma (Rb) and its implications in Mexico. We analyzed clinical and demographic data of patients with Rb at select hospitals with Rb programs or that treat and refer patients with Rb, and identified the gaps in practice. We propose solutions to improve diagnosis, provide adequate treatment, and improve patient uptake.

METHODS

A general review was conducted on PubMed of peer-reviewed literature on Rb in Mexico. Ophthalmology Department Heads or Directors of Rb programs at seven hospitals in Mexico were contacted for data available on their patients with Rb.

RESULTS

Five hospitals provided clinical data on 777 patients with Rb in a period spanning 2000-2015. Of the 122 patients with treatment, 83.4% underwent enucleation. From 33 to 45.3% of Rb tumors in Mexico reach an advanced intraocular stage of development. Knowledge of the disease is limited, despite the fact that the Mexican Retinoblastoma Group has elaborated Rb treatment guidelines and is developing a national Rb registry. Especially in the Southern states, prevalence and outcomes are comparable to African and Asian countries, and only few patients are referred to national treatment centers. Only three institutions have comprehensive Rb programs.

CONCLUSIONS

There is an immediate need in Mexico to expand primary care providers' knowledge of Rb and to expand and upgrade current Rb programs to meet the needs of the population adequately. Diagnosis and care of Rb patients in Mexico can also be improved by the establishment of a national Rb registry and a national early detection program, and by increased use of the national treatment protocol.

[Care pathways before diagnosis in children and adolescents with malignancies]

OBJECTIVE

to describe medical care pathways between first symptoms and first oncologic consultation in children and adolescents with solid cancers in order to analyze a possible relationship between delayed diagnosis and its potential consequences.

METHODS

Retrospective study on patients aged less than 25 years at first consultation in the oncology department of pediatric, adolescent and young adult in Institut Curie during one year. Were collected data on cancer characteristics, components of care pathways, and sociodemographic parents' characteristics.

RESULTS

Hundred and six patients were selected, with median age of 6 years. Most represented tumor was low-grade cerebral tumor (17.0%). Pain was the most frequent type of disorder observed as first sign (34.3% of patients). First signs were unspecific in only 27.6% of cases. Most patients were first seen by a general practitioner (29.3%). Median total time to diagnosis was one month [ranges: 0-64]. Median number of consultations before referral to oncology expert was 2 [0-7]. Retrospective analysis found a possible delayed diagnosis in 44.3% of patients, with potential vital and functional risks estimated respectively at 14.1 and 20.7% of overall population. Time to diagnosis was shorter if father was of foreign nationality vs. French (34 days vs. 72 days, P<0.05), and longer if parents were separated (74.5 days vs. 42.5 days, P<0.03).

CONCLUSIONS

Overall time to diagnosis is quite fast, even if first signs of pediatric cancers are very polymorphic. Some medical and sociodemographic factors could influence characteristics of care pathways.

Factors associated with the latency to diagnosis of childhood cancer in Peru

BACKGROUND

The latency to diagnosis is the time between the detection of a patient's first symptoms and the cancer diagnosis. The aim of this study was to identify the latency to the diagnosis of cancer in children in Peru and the clinical and sociodemographic factors associated with this latency.

METHODS

All patients diagnosed with lymphoma and solid tumors between 2012 and 2014 at a social security referral hospital in Peru were retrospectively evaluated. Clinical and demographic variables were analyzed to assess their association with the latency to diagnosis.

RESULTS

A total of 284 patients younger than 18 years of age were included in the study. The median time to diagnosis was 8.8 weeks, with a median patient interval of 2 weeks and diagnostic interval of 4.4 weeks. We found significant differences in the latency to diagnosis for different types of cancer (longer for Hodgkin lymphoma and shorter for Wilms tumor). Older children had significantly longer latencies to diagnosis (P = 0.048; OR: 1.05, 95% CI [1.0-1.1]), as did children who were first diagnosed by a general physician rather than by a pediatrician or surgeon (P = 0.028; OR: 2.1, 95% CI [1.1-4.2]). Parental age, level of education, marital status, metastatic disease, clinical stage, and gender did not significantly affect latency to diagnosis as analyzed by a multivariate analysis.

CONCLUSION

In Peru, median latency to diagnosis was comparable to that described in developing countries, where the index of suspicion for childhood cancer remains low. It is crucial to establish strategies to optimize early diagnoses using associated factors.

Prediagnostic Intervals in Retinoblastoma: Experience at an Oncology Center in Brazil

Purpose

Retinoblastoma is the most common intraocular malignancy of childhood. In most cases, parents are the first to notice leukocoria and other symptoms before undergoing a prolonged period of stress before diagnosis. The purpose of this study was to determine prediagnostic intervals of patients with retinoblastoma at an oncology tertiary center (Instituto Nacional de Cancer) in Rio de Janeiro, Brazil, and relate them to stage at diagnosis, eye salvage, and survival.

Methods

Parents or caregivers of children with retinoblastoma registered between January 2006 and September 2013 were interviewed using a semistructured individually applied questionnaire, concerning their trajectory before registration.

Results

Out of 76 patients, 39 (51%) were girls, 52 (68%) had unilateral retinoblastoma, and 24 (32%) had bilateral retinoblastoma, totaling 100 affected eyes. The most common stage of diagnosis was the intraocular group, with 63 (83%) patients; nine (12%) were extraocular, and four (5%) had metastatic disease. During the follow-up time of 37 ± 24.5 months, 10 (13%) patients died and 70 (70%) eyes were enucleated. Mean family interval was 1.6 ± 2.6 months, mean medical interval was 5.0 ± 6.2 months, mean referral interval was 0.2 ± 1.4 months, and mean overall interval was 7.1 ± 6.9 months. In univariate analysis, age at diagnosis, maternal education, medical interval, and overall interval were significantly related to advanced stage at diagnosis and survival. In multivariate analysis, maternal education and medical interval were significantly related to advanced stage at diagnosis and survival. No variables affected eye salvage.

Conclusion

Medical interval was responsible for 70% of the overall interval; therefore, programs or campaigns targeting retinoblastoma early diagnosis should focus emphasize in medical awareness.

Multimodal Therapy for Stage III Retinoblastoma (International Retinoblastoma Staging System): A Prospective Comparative Study

PURPOSE

To compare the efficacy of 2 chemotherapeutic drug combinations as part of multimodal therapy for orbital retinoblastoma.

DESIGN

Prospective, comparative, study.

PARTICIPANTS

Patients with stage III retinoblastoma (International Retinoblastoma Staging System).

METHODS

Demographic and clinical features were recorded at presentation. Treatment consisted of a multimodal protocol with neoadjuvant chemotherapy, enucleation, orbital external-beam radiotherapy, and adjuvant chemotherapy. For chemotherapy, patients were randomized into 2 groups: group A patients were treated with vincristine, etoposide, and carboplatin (VEC) and group B patients were treated with carboplatin and etoposide, alternating with cyclophosphamide, idarubicin, and vincristine. Treatment outcomes and adverse effects were recorded. Efficacy parameters were compared between the groups.

MAIN OUTCOME MEASURES

Survival probability, cause of death, and chemotherapy-related toxicity.

RESULTS

A total of 54 children were recruited (27 in each group). The mean ± SD follow-up was 21.3±11.34 months. The overall Kaplan-Meier survival probability was 80% (95% confidence interval [CI], 0.67-0.89) and 42% (95% CI, 0.24-0.59) at 1 year and 4 years, respectively. There were 9 deaths in group A and 15 deaths in group B. The Kaplan-Meier survival probability at 1 year was similar between the groups: 81% (95% CI, 0.60-0.91) and 79% (95% CI, 0.58-0.9) for groups A and B, respectively. At 4 years, the survival probability for group A was higher (63% [95% CI, 0.41-0.79] vs. 25% [95% CI, 0.08-0.46] for groups A and B, respectively), with a strong trend of better survival in group A over time (P = 0.05). The major cause of death was central nervous system relapse (8 patients in group A and 7 patients in group B). Two patients in group B died of sepsis after febrile neutropenia. Grade 3 and grade 4 hematologic toxicities were more common in group B, with a significant difference in grade 4 neutropenia (P = 0.002).

CONCLUSIONS

This study compared the outcomes of VEC chemotherapy with a 5-drug combination of etoposide and carboplatin, alternating with cyclophosphamide, idarubicin, and vincristine, for stage III retinoblastoma. The VEC combination was found to be more effective and may be recommended as neoadjuvant and adjuvant chemotherapy.

A Prospective Study on the Causes of Delayed Diagnosis of Childhood Cancer in Ibadan, Nigeria

Outcome in cancer may be improved by early diagnosis and prompt treatment. The objectives of this study were to determine the prediagnostic intervals (lag time) in childhood cancer and the factors that influence them at the University College Hospital (UCH), Ibadan. The study was prospective and observational and involved children diagnosed with cancer from July 2012 to June 2014 at UCH, Ibadan, Nigeria. A history of the illness was obtained and physical examination performed on each patient. Information obtained and analyzed included sociodemographic data, cancer diagnosis and stage, time intervals between onset of symptoms and diagnosis, and the reasons for delayed diagnosis. A total of 91 children were studied, comprising 46 males and 45 females. Their ages ranged from 1 month to 15.0 years, with a median of 4.0 years. Median parent lag time was 2.0 weeks, median health system or physician lag time 8.0 weeks, and median overall lag time 15.5 weeks. Overall lag time had a negative correlation with age of child at diagnosis, a positive correlation with the number of health facilities visited before diagnosis, and was shorter in mothers younger than 40 years of age. Lag time was significantly different among the diagnostic tumor categories, with Burkitt lymphoma having short times and retinoblastoma with long times. Delayed diagnosis of childhood cancer is a significant problem in Ibadan. Education of parents and health workers on early presentation and accurate diagnosis are recommended.

Disparities in Retinoblastoma Presentation, Treatment, and Outcomes in Developed and Less-Developed Countries

Retinoblastoma (RB) is the most common intraocular malignancy in children. In the past century, RB survival rates in developed countries (DCs) have improved from <5% to as high as 99%. In contrast, in less developed countries (LDCs) where the tumor burden is greatest, survival rates remain poor, with some countries reporting survival rates as low as 0-5%. In addition, there are disparities between DCs and LDCs in RB presentation, treatment modalities, and prognosis. These disparities are due to many underlying causes, including delays in diagnosis, access to medical care, patient and physician familiarity with the disease, availability and cost of treatment, and patient acceptance of enucleation. It is our belief that attempts to extend the improvements in prognosis achieved in DCs to various LDCs must be culturally sensitive and tailored to each country's specific challenges, and thus, a "one-size-fits-all" approach to improving patient outcomes in LDCs is unlikely to work well. We discuss several culturally sensitive approaches that have been successfully implemented in various LDCs, including those that make use of telemedicine and "twinning" with centers of excellence around the world.

Retinoblastoma in a pediatric oncology reference center in Southern Brazil

Background

Retinoblastoma (Rb) is the most common intraocular tumor diagnosed in children in Brazil. However, detailed information is lacking regarding patient clinical demographics. This study aimed to determine the clinical profile of patients with Rb who were treated in a public university hospital in southern Brazil from 1983 to 2012. Methods: Patients’ medical records were reviewed to retrospectively identify patients with a principal diagnosis of Rb. Rb was classified as hereditary or non-hereditary. Clinical staging was reviewed by an ophthalmologist. Statistical analysis was performed using SPSS.

Results

Of 165 patients with a diagnosis of Rb during this period, 140 were included in the study. Disease was unilateral in 65.0 % of patients, bilateral in 32.9 %, and trilateral in 2.1 %. The mean age at onset of the first sign/symptom was 18.1 month, and 35.7 % of patients were diagnosed during the first year of life. The most common presenting signs were leukocoria (73.6 %) and strabismus (20.7 %). The mean age at diagnosis was 23.5 months, and time to diagnosis was 5.4 months. In patients with clinical features of hereditary Rb, both onset of the first sign/symptom and diagnosis were at an earlier age than in patients without these features (12.3 vs 21.6 months [P = 0.001] and 15.9 vs 28.0 months [P < 0.001], respectively). However, there was no significant difference in overall survival between the two groups. Ocular stage at diagnosis was advanced in 76.5 % (Reese V) and 78.1 % (International Classification D or E). Of patients with unilateral and bilateral disease, 35.2 % and 34.8 %, respectively, had extraocular disease at diagnosis; 10.7 % had metastatic disease at diagnosis. Enucleation was observed in 88.1 % and exenteration in 11.9 % of patients; 93.6 % patients were followed until 2012, and 22.9 % relapsed. Overall survival was 86.4 %.

Conclusions

Most Rb diagnoses are still diagnosed in advanced stages of the disease, considerably reducing overall survival time and the rate of eye and vision preservation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-016-0579-9) contains supplementary material, which is available to authorized users.

Retinoblastoma in Mongolia: Clinical characteristics and survival from 1987 to 2014

Background/Purpose:

This study aims to describe the clinical characteristics and treatment outcome of retinoblastoma in Mongolian children.

Methods:

Data of all children diagnosed with retinoblastoma at the National Center for Maternal and Child Health of Mongolia from 1987 to January 2014 were reviewed retrospectively. The ICRB classification was used. Survival characteristics of the cohort were analyzed.

Results:

Retinoblastoma was diagnosed in 79 eyes of 64 cases during the study period. Median age of diagnosis was 24.5 ± 15.8 months. There were no differences in sex ratio, and 15 cases (23%) were bilateral. Forty-three (67%) patients were from rural areas. The more frequent clinical presentations were leukocoria in 50 (78%) patients, strabismus in 24 (38%) patients, and glaucoma in 21 (33%) patients. Sixty-one (95%) patients were diagnosed with Classification D or worse when presented to us. Due to late diagnosis in the majority of cases, unilateral and bilateral enucleations were performed in 48 (61%) eyes and 24 (30%) eyes, respectively; exenteration was done in three (4%) eyes. Fifty-two (81%) patients received chemotherapy and 13 (8.3%) patients underwent external beam radiation after enucleation. At the time of last follow-up, 52 (81%) patients were alive, five (8%) patients were dead, and seven (11%) patients had lost to follow-up or unknown vital status. The mean follow-up period was 121.5 months (range, 12–360 months). In five cases with immunohistochemistry analysis in the eye specimen, neuron-specific enolase-, Ki-67 protein-, and B-cell lymphoma 2-positive cells were found in all five (100%) cases and Rb protein was detected in three (60%) cases.

Conclusion:

Retinoblastoma in Mongolia is frequently diagnosed at late stages and has a poor outcome. These data show the importance of early pediatric eye examinations and better treatment of retino-blastoma in children younger than 3 years in Mongolia.

Epidemiology of childhood and adolescent cancer in Bangladesh, 2001-2014

BACKGROUND

Cancer burden among children and adolescents is largely unknown in Bangladesh. This study aims to provide a comprehensive overview on childhood and adolescent cancers and to contribute to the future strategies to deal with these diseases in Bangladesh.

METHODS

Data on malignant neoplasms in patients aged less than 20 years diagnosed between 2001 and 2014 (N = 3143) in Bangladesh was collected by the National Institute of Cancer Research and Hospital and ASHIC Foundation. The age pattern and distribution of cancer types were analysed and the incidence rates were calculated.

RESULTS

The age-standardised incidence rate was 7.8 per million person-years for children (0-14 years) in the last time period (2011-2014). Retinoblastoma (25%) and leukaemia (18%) were the most common childhood cancers. For adolescents (15-19 years), the age-specific incidence rate was 2.1 per million person-years in the same time period. Most common adolescent cancers were malignant bone tumours (38%), germ cell and gonadal tumours (17%), and epithelial tumours (16%). There were more boys affected (M: F ratio 2.0 in children and 1.4 in adolescents) than girls.

CONCLUSION

Cancer incidences were lower than expected most likely due to a low level of awareness about cancer among clinicians and the population, inadequate access to health care, lack of diagnostic equipment and incomplete recording of cases. Improvements on different levels should be made to get a better epidemiologic insight and to detect cancer earlier resulting in a better outcome for affected children and adolescents.