A multicentre report from the Mexican Retinoblastoma Group

Strategies to improve diagnosis and access to treatment of retinoblastoma in low- and middle-income countries: A systematic review

Retinoblastoma, the most common intraocular tumor in childhood, still faces challenges in diagnosis and treatment, particularly in low- and middle-income countries. Identifying strategies to improve the time to diagnosis and access to treatment is crucial to enhance survival rates and preserve ocular health. We conducted a systematic review to identify interventions that have demonstrated potential in addressing these challenges. We performed a comprehensive search across databases until March 2023. Out of the studies reviewed, 21 met the inclusion criteria and were categorized into five main areas: surveillance strategies, genetic counseling, education, public assistance, and international partnership. Despite the obstacles faced, the initiatives identified in this review present acts toward improving the time to diagnosis and access to treatment for retinoblastoma. Based on the extracted data, we propose a comprehensive chain of initiatives. We firmly believe that implementing this chain of initiatives can lead to improved clinical outcomes for retinoblastoma patients.

Retinoblastoma in the Southern Philippines: Clinical Outcomes of Retinoblastoma Patients in a Davao Tertiary Hospital

Background

Retinoblastoma is the most common intraocular cancer in childhood in the Philippines. Most data though on demographics, clinical profile, treatment options, and outcomes in the country are from the National Capital Region.

Objectives

This study aimed to describe the demographics, clinical profile, treatment done, and outcomes of retinoblastoma patients seen in a public tertiary referral center in Davao from 2011-2020 to make available literature more representative of the status of retinoblastoma in the Philippines.

Methods

An analytical cross-sectional study was conducted using the records of retinoblastoma patients seen in a tertiary government hospital located in Davao Region from January 2011 to December 2020.

Results

There were 157 patients included in the analysis. Seventy-three (46%) were female with 44% coming from the Davao Region. One hundred seven (69%) patients had unilateral disease. Median age at initial consultation for patients with unilateral disease was significantly older than those with bilateral disease (p<0.003). Tumors were extraocular in 82 (40%) eyes. In the intraocular group, 36% of the eyes belonged to International Classification of Retinoblastoma (ICRB) Groups D and E. Enucleation was the most commonly performed treatment. Survival rate was 28%.This is the first report to provide epidemiologic and clinical data on retinoblastoma in the literature, including survival data, from Mindanao. Advanced stages and extraocular cases of retinoblastoma remain high. Delay of consultation contributed to the prognosis and clinical outcome of the disease.

Conclusion

Advanced stages and extraocular cases of retinoblastoma remain significantly high in the country, even in Mindanao.

Retinoblastoma treatment in a Brazilian population. Presentation and long-term results

INTRODUCTION

Retinoblastoma is a malignant tumor with a high cure potential when proper therapy is used. The purpose of this paper is to report the clinical features and outcomes of patients with retinoblastoma who were treated with a combination of local and systemic chemotherapy-based protocols.

METHOD

We retrospectively studied patients treated with systemic chemotherapy plus local treatment between 2003 and 2015 with a follow-up ≥2 years. We correlated clinical and pathological characteristics with decimal visual acuity (VA) and death.

RESULTS

Among 119 patients, 60% had unilateral disease (UNI), and 52% were male. The median presentation age was 19.5 months, 10% had a positive family history, and the most frequent sign was leukocoria (68.8%). Advanced disease was more frequent in eyes with UNI (98.4%) than in eyes with bilateral retinoblastoma (BIL: 55.3%). Enucleation was performed in 97% of UNI eyes and in 55.8% of BIL eyes. The overall globe salvage was 26.6%, 44.25% of BIL eyes. Bilateral enucleation was required in 5%. High-risk pathologic features occurred in 50% and 37% of eyes enucleated without and with neoadjuvant chemotherapy, respectively. High-risk features were related to the presence of goniosynechiae in the pathologic specimen and were more frequent in children younger than 10 months or older than 40 months. Extraocular disease was present in 5% of patients, and the death rate related to metastasis of the tumor was 8%. The final VA was ≥ 0.7 in 72.8% and ≥0.1 in 91% of BIL patients.

CONCLUSIONS

Treatment of retinoblastoma with conservative systemic-based chemotherapy was associated with an excellent survival rate (92%). Albeit the low overall globe salvage rate, in BIL patients, approximately half the eyes were conserved, and a satisfactory functional visual result was achieved The evaluated protocol is an important treatment option, especially in developing countries.

Clinical analysis of 2790 children with retinoblastoma: a single-center experience in China

BACKGROUND

In this study, we aimed to analyze the clinical characteristics and prognosis of children with retinoblastoma (RB) in a single center in China with a large sample collection spanning 17 years.

METHODS

The clinical data of 2790 children with RB treated in Beijing Tongren Hospital from 2005 to 2021 were collected, and a retrospective analysis was conducted.

RESULTS

The median age of the participants was 28.3 months. There were 3624 affected eyes, 12.4% of which were in groups A-C, 67.1% in groups D-E and 16.2% were not specified. The primary symptom observed in most cases was a white pupil, accounting for 66.5%, followed by strabismus (12.8%). The median follow-up time was 59.7 months. The enucleation rate was 71.3% (703/986) in a single left eye and 72.5% (702/968) in a single right eye. The overall survival (OS) rate was 95.8% (2444/2552) because 237 patients dropped out, and 109 died. Kaplan‒Meier survival analysis showed that the median survival time (MST) was 125.92 months [95% confidence interval (CI) = 124.83-127.01]. Cox multivariate survival analysis showed that trilateral RB (P = 0.017), metastasis site (P = 0.001), and combined distant tissue metastasis (P = 0.001) were independent prognostic factors for RB. The OS of 44 cases of familial RB was 93.2% (41/44), with an MST of 80.62 months (95% CI = 67.70-93.54).

CONCLUSIONS

The timing of eye protection treatment and enucleation should be comprehensively judged to avoid worsening prognosis due to operation time delay. More importantly, the promotion and popularization of diagnosis and treatment technologies are necessary to further improve RB prognosis.

RB1 gene mutations and genetic spectrum in retinoblastoma cases

The aim of the study was to investigate the frequency and types of mutations on the retinoblastoma gene (RB1 gene) in Turkish population. RB1 gene mutation analysis was performed in a total of 219 individuals (122 probands with retinoblastoma, 14 family members with retinoblastoma and 83 clinically healthy family members). All 27 exons and close intronic regions of the RB1 gene were sequenced for small deletions and insertions using both the Sanger sequencing or NGS methods, and the large deletions and duplications were investigated using the MLPA analysis and CNV algorithm. The bilateral/trilateral retinoblastoma rate was 66% in the study population. The general frequency of RB1 gene mutation in the germline of the patients with retinoblastoma was 41.9%. Approximately 51.5% of the patients were diagnosed earlier than 12 months old, and de novo mutation was found in 32.4% of the patients. Germline small genetic rearrangement mutations were detected in 78.9% of patients and LGRs were detected in 21.1% of patients. An association was detected between the eye color of the RB patients and RB1 mutations. 8 of the mutations detected in the RB1 gene were novel in the study.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Retinoblastoma and uveal melanoma in Jordan: incidence, demographics, and survival (2011-2020)

PURPOSE

We present an epidemiologic analysis of retinoblastoma (RB) and uveal melanoma (UM) in Jordan to aid national strategies for improved ocular cancer surveillance and control.

METHODS

A retrospective cohort of all Jordanian patients with RB and UM diagnosed over 10 years (2011-2020). Outcome measures included incidence, demographics, and outcomes.

RESULTS

Retinoblastoma (n = 124) was more common than UM (n = 82); there was no sex predilection for either group. The median age at diagnosis of RB was 15 months(Six and 28 months for bilateral and unilateral cases, respectively), and the mean age-adjusted incidence was 8.2 cases per-million-children per year for children aged five years or less(one per 15,620 newborn per year). Fifty-one(41%) had bilateral disease, and 18(15%) had familial disease. Ninety-six(55%) eyes were group D or E(78% were T3/T4), and the five-year survival rate was 96%.For UM, the median age at diagnosis was 45 years with an incidence of 1.39 new cases per year per one million population. All(100%) had nonfamilial unilateral disease. Seventy-three(89%) had the tumor in the choroid, and 48(58%) had an advanced tumor that had invaded the sclera or the orbit (T3/T4) tumor. Sixty-two(76%) were treated by I-125 radioactive plaque, with globe salvage in 59(95%); the five-year survival rate was 85%.

CONCLUSION

In Jordan, RB is more common and has better survival than UM. RB in Jordan and Western countries is equal in terms of incidence, globe salvage, and survival. UM is less common, with lower age at diagnosis (that was associated with better survival) in Jordan than in Western countries.

Presentation and management outcomes of Retinoblastoma among Syrian refugees in Jordan

Purpose

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

Methods and Materials

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

Results

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

Conclusion

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

Retinoblastoma: A review of clinical profile at a regional cancer center in Northwest India

Background

Retinoblastoma is the most common primary intraocular malignancy of childhood. The present study was undertaken to overcome the scarcity of data regarding the epidemiology, demographic and clinical profile, and nature of the first health-care professional consulted.

Materials and Methods

A retrospective analysis of medical records was performed for all cases of retinoblastoma who presented to the department of ophthalmology and oncology between 2010 and 2017. A total of 54 cases were reviewed.

Results

Unilateral disease was seen in 85.2% while 14.8% presented with bilateral disease with a median age of 3 years and 2 years, respectively, at diagnosis. The male: female ratio was 2:1. The most common presenting symptom was leukocoria which was noticed in 42 patients (77.7%), followed by red eye (33.3%) and proptosis (20.3%). The most common stage of presentation was Stage I (44.4%), followed by Stage IV (20.4%), Stage III (9.3%), and Stage II (5.6%). The median time to diagnosis was 8.7 months (range, 0.5-98.7 months), and the median time to treatment was 37.4 days (range, 0-645 days). Majority of the patients were referred by local ophthalmologists (48%), followed by general practitioners (20%), nurses (19%), and quacks (13%). Enucleation was the most preferred treatment modality (48.1%), followed by chemotherapy (33.3%), radiotherapy (13%), photocoagulation (3.7%), and exenteration (1.9%). The overall remission rate was 79.6%, while 12.3% had relapse and 7.4% died.

Conclusion

The study showed a dire need for timely detection and treatment of retinoblastoma which is possible with improved awareness and better accessibility to health-care facilities. It also revealed a decrease in histopathological risk factors with chemoreduction.

Clinical Features, Treatment, and Outcomes of Retinoblastoma in China

Background This review determined clinical features and treatment outcomes of retinoblastoma patients in China, which ranks second in incidence globally and is among the countries listed to produce 4,000 new cases of the estimated world's retinoblastoma cases in 2023.

Methods A search was done using different databases for literatures on retinoblastoma in China published from 2010 to 2020. The articles were then reviewed for clinical features, treatment, and outcomes.

Results Ten articles that included 3,702 patients involving ∼4,412 eyes seen in China from 1957 to 2019 were analyzed. Median age at consult ranged from 18 to 30 months and mean lag of consultation was 4 to 6 months. More males were affected (58%). Seventy-nine percent had unilateral disease. Retinoblastoma was assumed intraocular in 4,123(89%) eyes with ≥996(22%) belonging to group E of International Intraocular Retinoblastoma Classification/International Classification of Retinoblastoma. Extraocular extension was present in 415 (9%) eyes with 845 patients having direct extraocular extension, while 54 had distant metastasis. Enucleation was the most used treatment procedure specially in unilateral disease done in at least 2,781 (74%) eyes. Median follow-up period ranged from 14 to 47 months. Functional vision was retained in 48 (2%) eyes. Globe salvage rate for group A to D eyes ranged from 56 to 100%. Highest globe salvage rate for group D was 87% and 70% for group E. Overall survival rate was 1,655/1898 (87%), ranging from 81 to 100%. Overall mortality was 4%.

Discussion Clinical profile and management options for retinoblastoma in China changed overtime improving outcomes. Globe salvage and survival rate were high for those with intraocular disease.

Krüppel-like transcription factor 16 transcriptional up-regulation of cellular retinoic acid-binding proteins-2 promotes the invasion and migration and inhibits apoptosis of retinoblastoma cells by regulating integrin-β1/focal adhesion kinase /extracellular signal-regulated kinase pathway

As a common intraocular malignancy in pediatrics, retinoblastoma (RB) has high prevalence worldwide. We conducted this study, aiming to explore the molecular mechanism of Krüppel-like transcription factor 16 (KLF16)/cellular retinoic acid-binding proteins-2 (CRABP2) in regulating the invasion and migration and apoptosis of RB cells via integrin-β1/focal adhesion kinase (FAK)/extracellular signal-regulated kinase (ERK) pathway. With the adoption of real-time quantitative polymerase chain reaction (RT-qPCR) and Western blot, the mRNA and protein expression of CRABP2 and KLF16 were measured. In addition, the proliferation, clone formation ability and migration were detected with methyl thiazolyl tetrazolium (MTT), clone formation and wound healing assays, respectively. Furthermore, the invasion and apoptosis of transfected WERI-RB1 cells were evaluated with transwell and Tunel assays. With the application of Western blot, the expressions of proliferation-, apoptosis- and pathway-related proteins were assayed. The combination of KLF16 and CRABP2 was confirmed by dual-luciferase reporter assay and chromatin immunoprecipitation (ChIP). In this study, we found that CRABP2 gained a huge growth in RB cells and its silence promoted apoptosis but suppressed the proliferation, migration and invasiveness of WERI-RB1 cells. In addition, KLF16 could bind to CRABP2. It was also found that KLF16 overexpression reversed the effects of CRABP2 silence on the proliferation, migration and apoptosis of WERI-RB1 cells. What is more, CRABP2 silence blocked integrin-β1/FAK/ERK signaling pathway. In conclusion, KLF16 transcriptional up-regulation of CRABP2 promoted proliferation, invasion and migration but inhibited apoptosis of RB cells by activating integrin-β1/FAK/ERK pathway.

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.

Successful Treatment of Late Isolated Bone Metastasis in a Patient with Bilateral Retinoblastoma Using an Unconventional Method

Though survival in bilateral retinoblastoma (RB) has improved due to advancement in diagnostics and treatment modalities, children require long-term follow-ups for recurrence and second malignancies. We report a case of bilateral RB in a 7-month-old baby who was treated with chemotherapy, transpupillary thermotherapy, and periocular carboplatin for both eyes following which there was complete regression of tumour. Six and a half years after treatment, the child presented with metastatic recurrence of tumour in the left ulna. He was treated successfully with chemotherapy, extracorporeal radiation and reimplantation therapy. A less aggressive treatment approach for isolated bone relapse may be considered in selected cases.

Less is more: new one-step intracameral chemotherapy technique

Purpose: To describe the feasibility of a new one-step approach to aspirate the aqueous and apply melphalan in a single-go without repeated entries into the anterior chamber. Methods: This retrospective non-comparative study was conducted at a referral center and included 12 patients. The one-step approach is described in a step-wise manner. No complications were observed among the patients. Results: One single injection of intracameral melphalan proved to be a successful treatment in nine cases. Two patients required a second injection, which was administered two weeks after the first one following the same technique. Conclusions: This proved to be a reasonable technique for the smooth application of melphalan in the anterior chamber studded with retinoblastoma seeds. Our outcomes revealed that it is an effective, quick, and cost-effective technique. Longer-term data collection is underway, though initial findings are encouraging.

Recent advancements in the management of retinoblastoma and uveal melanoma

Retinoblastoma in children and uveal melanoma in adults can pose a serious threat to both vision and life. For many decades, enucleation was often the only option to treat these intraocular malignancies. For retinoblastoma, intra-arterial chemotherapy is often utilized as the primary treatment at advanced academic centers and has dramatically improved local tumor control and eye salvage rates. For uveal melanoma, both plaque brachytherapy and proton beam irradiation have served as widely utilized therapies with a local failure rate of approximately 1–10%, depending on the series. Major recent advancements have allowed for a better understanding of the genomics of uveal melanoma and the impact of certain mutations on metastatic susceptibility. Gene expression profile stratifies uveal melanomas into two classes: low-risk (class 1) and high-risk (class 2). A loss-of-function mutation of BAP1 is associated with a class 2 gene expression profile and therefore confers worse prognosis due to elevated risk of metastasis. On the other hand, gain-of-function mutations of EIF1AX and SF3B1 correspond to a gene expression profile of class 1A and class 1B and confer a better prognosis. Preferentially expressed antigen in melanoma (PRAME) is an antigen that increases metastatic susceptibility when expressed in uveal melanoma cells. In addition to plaque brachytherapy and proton beam irradiation, both of which have demonstrated superb clinical outcomes, scientists are actively investigating newer therapeutic modalities as either primary therapy or adjuvant treatment, including a novel nanoparticle therapy and immunotherapy.

Global Retinoblastoma Treatment Outcomes: Association with National Income Level

PURPOSE

To compare metastasis-related mortality, local treatment failure, and globe salvage after retinoblastoma in countries with different national income levels.

DESIGN

International, multicenter, registry-based retrospective case series.

PARTICIPANTS

Two thousand one hundred ninety patients, 18 ophthalmic oncology centers, and 13 countries on 6 continents.

METHODS

Multicenter registry-based data were pooled from retinoblastoma patients enrolled between January 2001 and December 2013. Adequate data to allow American Joint Committee on Cancer staging, eighth edition, and analysis for the main outcome measures were available for 2085 patients. Each country was classified by national income level, as defined by the 2017 United Nations World Population Prospects, and included high-income countries (HICs), upper middle-income countries (UMICs), and lower middle-income countries (LMICs). Patient survival was estimated with the Kaplan-Meier method. Logistic and Cox proportional hazards regression models were used to determine associations between national income and treatment outcomes.

MAIN OUTCOME MEASURES

Metastasis-related mortality and local treatment failure (defined as use of secondary enucleation or external beam radiation therapy).

RESULTS

Most (60%) study patients resided in UMICs and LMICs. The global median age at diagnosis was 17.0 months and higher in UMICs (20.0 months) and LMICs (20.0 months) than HICs (14.0 months; P < 0.001). Patients in UMICs and LMICs reported higher rates of disease-specific metastasis-related mortality and local treatment failure. As compared with HICs, metastasis-related mortality was 10.3-fold higher for UMICs and 9.3-fold higher for LMICs, and the risk for local treatment failure was 2.2-fold and 1.6-fold higher, respectively (all P < 0.001).

CONCLUSIONS

This international, multicenter, registry-based analysis of retinoblastoma management revealed that lower national income levels were associated with significantly higher rates of metastasis-related mortality, local treatment failure, and lower globe salvage.

How Telemedicine and Centralized Care Changed the Natural History of Retinoblastoma in a Developing Country: Analysis of 478 Patients

PURPOSE

To evaluate the efficacy of integrating a telemedicine-based twinning partnership and centralized care for retinoblastoma on survival and eye salvage.

DESIGN

Four hundred seventy-eight retinoblastoma patients treated at a tertiary referral cancer center (King Hussein Cancer Centre [KHCC]) from 2003 through 2019.

PARTICIPANTS

Four hundred seventy-eight retinoblastoma patients treated at KHCC after implementing a telemedicine-based program with St. Jude Children's Research Hospital.

METHODS

We reviewed the outcomes of retinoblastoma patients who were treated at KHCC after implementing a telemedicine-based eye salvage program with St. Jude Children's Research Hospital, and we compared that with outcomes for retinoblastoma patients who were treated before implementing a telemedicine-based retinoblastoma service at KHCC.

MAIN OUTCOME MEASURES

We analyzed patient demographics, clinical characteristics, treatments received, consultation type and duration, and long-term patient outcomes before and after implementing the twinning program.

RESULTS

Over 17 years, 813 eyes from 478 children with retinoblastoma were treated at KHCC. Three hundred thirty-five patients (70%) had bilateral disease. Six patients (4%) with unilateral disease and 66 patients (20%) with bilateral disease had a family history of retinoblastoma. After the twinning program was established in 2003, the mortality rate decreased from 38% to 5% (P < 0.0001), and the overall eye salvage rate increased from 4% to 61% (98% for group A, 93% for group B, 81% for group C, and 48% for group D; P < 0.0001). Initially, all cases were discussed via telemedicine, but as knowledge transfer increased, the proportion of cases that required discussion decreased to less than 3% 10 years later. Similarly, treatment changes based on consultations decreased from 70% to 7% after 10 years. Both survival and eye-salvage rates were comparable at the early and later stages of implementing the twinning program. At a median follow-up of 120 months, 5% of patients had died of metastases or secondary neoplasms, 81% were alive, and 14% were lost to follow-up.

CONCLUSIONS

Centralization of care at a single center in developing countries can achieve patient outcomes comparable with those of developed countries via twinning and telemedicine. This benefit can extend to a large region because two thirds of patients treated at KHCC were non-Jordanians.

A Multicenter, International Collaborative Study for American Joint Committee on Cancer Staging of Retinoblastoma: Part I: Metastasis-Associated Mortality

PURPOSE

To evaluate the ability of the 8th edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual to estimate metastatic and mortality rates for children with retinoblastoma (RB).

DESIGN

International, multicenter, registry-based retrospective case series.

PARTICIPANTS

A total of 2190 patients from 18 ophthalmic oncology centers from 13 countries over 6 continents.

METHODS

Patient-specific data fields for RB were designed and selected by subcommittee. All patients with RB with adequate records to allow tumor staging by the AJCC criteria and follow-up for metastatic disease were studied.

MAIN OUTCOME MEASURES

Metastasis-related 5- and 10-year survival data after initial tumor staging were estimated with the Kaplan-Meier method depending on AJCC clinical (cTNM) and pathological (pTNM) tumor, node, metastasis category and age, tumor laterality, and presence of heritable trait.

RESULTS

Of 2190 patients, the records of 2085 patients (95.2%) with 2905 eyes were complete. The median age at diagnosis was 17.0 months. A total of 1260 patients (65.4%) had unilateral RB. Among the 2085 patients, tumor categories were cT1a in 55 (2.6%), cT1b in 168 (8.1%), cT2a in 197 (9.4%), cT2b in 812 (38.9%), cT3 in 835 (40.0%), and cT4 in 18 (0.9%). Of these, 1397 eyes in 1353 patients (48.1%) were treated with enucleation. A total of 109 patients (5.2%) developed metastases and died. The median time (n = 92) from diagnosis to metastasis was 9.50 months. The 5-year Kaplan-Meier cumulative survival estimates by clinical tumor categories were 100% for category cT1a, 98% (95% confidence interval [CI], 97-99) for cT1b and cT2a, 96% (95% CI, 95-97) for cT2b, 89% (95% CI, 88-90) for cT3 tumors, and 45% (95% CI, 31-59) for cT4 tumors. Risk of metastasis increased with increasing cT (and pT) category (P < 0.001). Cox proportional hazards regression analysis confirmed a higher risk of metastasis in category cT3 (hazard rate [HR], 8.09; 95% CI, 2.55-25.70; P < 0.001) and cT4 (HR, 48.55; 95% CI, 12.86-183.27; P < 0.001) compared with category cT1. Age, tumor laterality, and presence of heritable traits did not influence the incidence of metastatic disease.

CONCLUSIONS

Multicenter, international, internet-based data sharing facilitated analysis of the 8th edition AJCC RB Staging System for metastasis-related mortality and offered a proof of concept yielding quantitative, predictive estimates per category in a large, real-life, heterogeneous patient population with RB.

Programmed screening for retinoblastoma enhances early diagnosis and improves management outcome for high-risk children

PURPOSE

To study the impact of a Retinoblastoma (Rb) screening program in the absence of genetic testing on the management and outcome of high-risk children.

METHODS

This is a retrospective, clinical case series of 76 children from families involved in a Rb screening program as they had higher than normal risk as calculated by the conventional ways without genetic testing. Data included calculated risk, method of diagnosis, demographics, tumor features, treatment modalities, and management outcome.

RESULTS

Out of the 76 children screened, 46 children were diagnosed with Rb (12 by screening and 34 had signs of Rb), the other 30 were free of disease. Patients diagnosed by screening were younger (mean; 2.4 months vs 15.8 months for the group with signs of Rb), had significantly earlier tumor stage at diagnosis (p = .0001), higher eye salvage rate (p = .0001), less need for systemic chemotherapy (p = .022), and better visual outcome (p = .0017) than the other group. None of the eyes were group D or E, enucleated or irradiated. Six (50%) patients were cured without chemotherapy, and the visual acuity was 0.5 or better in 55% of eyes. Of interest, 71% of tumors were diagnosed by the age of 6 months, 90% by the age of 1 year, and no new tumor appeared after the age of 2 years.

CONCLUSION

Even in the absence of genetic testing, screening for children with high risk for Rb is effective in enhancing early diagnosis, improving visual outcome, and increasing eye salvage rate with limited exposure to treatment burden.

A 20-year audit of retinoblastoma treatment outcomes

Objectives

To evaluate the long-term treatment outcomes in intraocular retinoblastoma (RB) including the associated factors for eventual treatment with external beam radiotherapy (EBRT) and enucleation as well as to analyse the risk factors for metastasis and death in extraocular RB.

Methods

Retrospective analysis of 390 eyes from 256 (89.8%) intraocular RB and 29 (10.2%) extraocular RB cases diagnosed and treated between October 1998 and May 2018 at one of the largest tertiary care centers in Turkey.

Results

Of 351 intraocular RB eyes, 53.3% had group D/E disease at presentation. 75 (21.4%) of 351 eyes underwent primary enucleation. Of the remaining 276 eyes undergoing eye-conserving treatments, 201 (72.8%) were salvaged. Most of these eyes were treated using intravenous chemotherapy and/or focal treatments [transpupillary thermotherapy (TTT) and cryotherapy] initially. EBRT was eventually required in 48 (17.4%) eyes and secondary enucleation in 75 (27.2%) eyes. At mean follow-ups of 76.7 and 39.7 months for intraocular and extraocular RB cohorts, respectively, 180 (46.2%) eyes underwent primary/secondary enucleation and exenteration. Overall, 13 cases developed metastasis and 9 died. Two patients with trilateral RB also expired. Multivariable risk factors for enucleation were the presence of vitreous seeds (p < 0.001), absence of EBRT administration (p = 0.033), 5–9 TTT applications compared with no TTT (p = 0.031), and each 1 mm increase in tumour base diameter (p < 0.001). Univariate factors predictive of metastasis were the presence of extraocular RB detected by imaging methods (p < 0.001) and extrascleral/optic nerve cut end involvement at histopathological examination (p < 0.001).

Conclusions

In our series, 72.8% of the intraocular RB eyes undergoing eye-conserving treatments were saved. The globe salvage rate for all intraocular and extraocular RB eyes was 53.8% and the overall survival rate was 96.1%.

Challenge of Retinoblastoma in Mexico in 2020: Perspectives and Solutions

Early diagnosis and positive outcomes of retinoblastoma in childhood have been positively correlated with the economic wealth of high-income countries (HICs) worldwide. Adequate curability and survival rates, adherence to treatment, presence of poor prognostic initial clinical signs, and metastatic disease at diagnosis appear to have a less favorable picture in low-income countries (LICs). However, this is not always the case. An example is Argentina, where disease-free survival rates of retinoblastoma are notably higher than expected when taking into consideration its economic situation. Unfortunately, as in other Latin American LICs, retinoblastoma outcomes in Mexico are worrisome. Interestingly, the Human Development Index (HDI) in Mexico varies widely between its different geographical regions. While in some states, the HDI resembles those of high-income countries, and in others, the opposite is observed. A unifying picture of Mexico's developmental status, health resources, indicators, and other factors possibly influencing outcomes in retinoblastoma is currently unavailable. The present review explores the previously mentioned factors in Mexico and compares them to other countries. Additionally, it recommends solutions or enhancements where possible.

Treatment of Nonmetastatic Unilateral Retinoblastoma in Children

Importance

Multi-institutional collaborative studies that include large patient populations for the management of retinoblastoma with histopathological risk factors could provide important information for patient management.

Objective

To evaluate the implementation of a strategy for the management of nonmetastatic unilateral retinoblastoma in children based on standardized diagnostic and treatment criteria.

Design, Setting, and Participants

This single-arm prospective study applied a strategy based on a single-center experience. The setting was a multicenter study in Latin America (Grupo de America Latina de Oncologia Pediatrica [GALOP]). Participants were children with nonmetastatic unilateral retinoblastoma (staged with the International Retinoblastoma Staging System). The study opened on July 1, 2008, and closed on December 31, 2014. Follow-up was updated until June 30, 2017.

Interventions

Stage 0 patients (without enucleation) were given conservative therapy without a protocol. Stage I patients (with enucleation and no residual tumor) were divided into a high-risk group (retrolaminar invasion and/or scleral invasion) and a low-risk group (all remaining patients). High-risk children received adjuvant chemotherapy with 4 alternating cycles of regimen 1 (cyclophosphamide [65 mg/kg/d] [plus sodium-2-mercaptoethane sulfonate], idarubicin hydrochloride [10 mg/m2/d], and vincristine sulfate [0.05 mg/kg/d]) and 4 cycles of regimen 2 (carboplatin [500 mg/m2/d, days 1 and 2] and etoposide [100 mg/m2/d, days 1-3]). Low-risk children did not receive adjuvant therapy. Children with buphthalmia received neoadjuvant and adjuvant chemotherapy for a total of 8 cycles.

Main Outcomes and Measures

Probability of event-free survival (extraocular relapse and death from any cause were considered events).

Results

Among 187 children registered in the study, 175 were evaluable (92 [52.5%] female; median age, 22 months; age range, 3-100 months). Forty-two were stage 0 children, 84 were stage I low-risk children, and 42 were stage I high-risk children; there were 7 children in the buphthalmia group. With a median follow-up of 46 months, the 3-year probability of event-free survival was 0.97 (95% CI, 0.94-0.99), and the probability of overall survival was 0.98 (95% CI, 0.94-1.00). Stage 0 patients had no events, stage I low-risk patients had 1 event (orbital relapse treated with second-line therapy), stage I high-risk patients had 2 events (1 central nervous system relapse and 1 death from sepsis), and the buphthalmia group had 1 event (orbital relapse, followed by central nervous relapse and death).

Conclusions and Relevance

Adjuvant therapy may be effective for high-risk unilateral retinoblastoma but is toxic, and neoadjuvant chemotherapy for buphthalmus appears feasible.

Overexpression of Biglycan is Associated with Resistance to Rapamycin in Human WERI-Rb-1 Retinoblastoma Cells by Inducing the Activation of the Phosphatidylinositol 3-Kinases (PI3K)/Akt/Nuclear Factor kappa B (NF-κB) Signaling Pathway

Background

Biglycan (BGN) is an extracellular matrix (ECM) protein that regulates the growth of epithelial cells. The mammalian target of rapamycin (mTOR) inhibitor, rapamycin, is a treatment for advanced retinoblastoma. This study aimed to investigate the effects of expression of BGN on the response of human WERI-Rb-1 retinoblastoma cells to rapamycin and to investigate the associated signaling pathways.

Material/Methods

BGN gene expression was induced in human WERI-Rb-1 retinoblastoma cells, which were incubated with rapamycin at doses of 0, 5, 10, 20, 30, and 50 μg/ml. Cells were treated with the PI3K/Akt pathway inhibitor, LY294002. The MTT assay determined the rate of cell inhibition. Real-time polymerase chain reaction (RT-PCR) was performed to measure BGN gene expression using RT²-PCR. Western blot detected the protein levels of BGN, p-PI3K, p-Akt, nuclear NF-κB, and p65.

Results

Rapamycin impaired cell growth, induced cell apoptosis, and suppressed the expression levels of p-PI3K, p-Akt, nuclear NF-κB, and p65. Overexpression of the BGN gene restored growth potential and inhibited apoptosis and was associated with the activation of the PI3K/Akt-mediated NF-κB pathway. In cells that overexpressed BGN, inhibition of the PI3K/Akt pathway by LY294002 increased the sensitivity of human WERI-Rb-1 retinoblastoma cells to rapamycin.

Conclusions

Overexpression of BGN induced rapamycin resistance in WERI-Rb-1 retinoblastoma cells by activating PI3K/Akt/NF-κB signaling.

Successful Treatment of Relapsed Isolated Extraocular Retinoblastoma in the Right Fibula With High-dose Chemotherapy and Autologous Stem Cell Transplantation

Literature on high-dose chemotherapy followed by autologous stem cell rescue in relapsed retinoblastoma is limited to <150 cases reported so far. We present our experience and the challenges faced in the management of a 7-year-old boy with relapsed isolated extraocular retinoblastoma in the right fibula who received salvage chemotherapy followed by high-dose chemotherapy and autologous stem cell rescue. Electrolyte disturbances, renal tubulopathy, and seizures were the most significant transplant-related morbidity. The child is now 3 years postautograft in remission. Monitoring for second malignant neoplasm and late side effects remain the main challenges in the years to come.

Antitumor Effects of 8-Deoxylactucin in RB355 Human Retinoblastoma Cells Are Mediated via Apoptosis Induction, Reactive Oxygen Species Production, and Cell Cycle Arrest

Background

Retinoblastoma is a rare malignancy arising from the immature cells of the retina, generally in children up to the age of 3 years. Here, we assessed the anticancer effects of a natural sesquiterpene lactone – 8-deoxylactucin – on the growth of the retinoblastoma RB355 and normal RPE cells.

Material/Methods

Cell viability was assessed by 3-(4,5-dimethylthiazol-2-Yl)-2,5-diphenyltetrazolium bromide (MTT) assay, and apoptosis was assessed by DAPI staining and annexin V/propidium iodide (PI) assay. Reactive oxygen species (ROS) levels were determined by fluorescence microscopy. Flow cytometry was used to determine the cell cycle distribution. Protein expression was determined by Western blot analysis.

Results

The results showed that 8-deoxylactucin exerted selective and potent anticancer effects on the RB355 cells and exhibited an IC₅₀ of 25 μM. Nonetheless, the cytotoxic effects of 8-deoxylactucin on the normal RPF cells were comparatively lower, as evident from the IC50 of 65 μM. 8-Deoxylactucin increased the production of ROS and triggering apoptosis of RB355 cells. The induction of 8-deoxylactucin-induced apoptosis was also accompanied with increased cleavage of caspase 3, upregulation of Bax, and downregulation of Bcl-2. The 8-deoxylactucin-induced cell cycle arrest of RB355 cells was also associated with inhibition of cyclin A and B1 expression, as well as the inhibition of Cdc2 phosphorylation.

Conclusions

8-Deoxylactucin inhibits the growth of RB355 cells by apoptosis, cell cycle arrest, and increased production of ROS.

Orbital relapse of retinoblastoma in patients with high-risk histopathology features

Aim:

To describe the clinical picture of orbital relapse of retinoblastoma following uncomplicated enucleation.

Methods:

Case series of two patients with group E retinoblastoma with high-risk features on histopathology, namely, post-laminar optic nerve extension in one patient, and massive choroidal tumor infiltration in the other. Neither of them received adjuvant chemotherapy post enucleation.

Results:

Both patients had orbital relapse of tumor within 4 months from enucleation, manifesting as implant migration and unstable conformer. Systemic chemotherapy and external beam radiotherapy to the orbit resulted in complete tumor regression. Both patients were tumor free at the last follow up.

Conclusion:

Implant migration post enucleation should raise the suspicion for orbital relapse of retinoblastoma. High-risk histopathology features should increase the alert in an otherwise uncomplicated enucleation for retinoblastoma.

VEGF overexpression is associated with optic nerve involvement and differentiation of retinoblastoma: A PRISMA-compliant meta-analysis

BACKGROUND

Vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of cancer. Although numerous studies have investigated the association between VEGF expression and pathogenesis of retinoblastoma, the results remained inconsistent. To illuminate the association, we performed a meta-analysis study.

METHODS

According to the PRISMA guideline, eligible studies were searched in the Medicine, Embase, Web of Science, Chinese National Knowledge Infrastructure, and Wanfang databases. Stata 14.0 software was used to calculate the relevant statistical parameters.

RESULTS

Seventeen studies with 296 controls and 470 patients with retinoblastoma were included from 17 eligible literatures. Overall, significant association between VEGF overexpression and susceptibility of retinoblastoma was observed in Chinese population (odds ratio [OR] = 21.67, 95% confidence interval [CI] = 13.96-33.62). Subgroup analysis based on control sample type showed that VEGF overexpression was significantly associated with the risk of retinoblastoma (Normal retina tissue, OR = 23.97, 95% CI = 9.67-59.42; retinoblastoma adjacent tissue, OR = 20.85, 95% CI = 12.64-34.37). Significant associations of VEGF overexpression with optic nerve involvement and differentiation of retinoblastoma were found (Optic nerve involvement, OR = 6.90, 95% CI = 4.01-11.88; Differentiation, OR = 0.18, 95% CI = 0.12-0.28). In addition, only 1 study was included to analyze the role of VEGF protein expression in the prognosis of retinoblastoma, and the result showed that VEGF expression was significantly associated with the prognosis of retinoblastoma, which should be verified in the future studies.

CONCLUSIONS

Our findings demonstrated that VEGF overexpression was significantly associated with the risk of retinoblastoma. Besides, the results suggested that VEGF overexpression might have a crucial effect on the optic nerve involvement and differentiation of retinoblastoma.

Anticancer Effects of Gingerol in Retinoblastoma Cancer Cells (RB355 Cell Line) Are Mediated via Apoptosis Induction, Cell Cycle Arrest and Upregulation of PI3K/Akt Signaling Pathway

Background

The main aim of the current investigation was to study the antiproliferative activity of gingerol in RB355 human retinoblastoma cancer cells. The effects of gingerol on apoptosis induction, cell cycle arrest, and PI3K/Akt signaling pathway were also evaluated.

Material/Methods

MTT cell viability assay was used to assess the cytotoxic effects of gingerol in these cells while. To study apoptotic effects in these cells, we used inverted microscopy along with fluorescence microscopy using acridine orange/propidium iodide and Hoechst 33258 as staining dyes. Flow cytometry was used to study cell cycle phase distribution and Western blot assay indicated effects on PI3K/Akt protein expression levels.

Results

Results showed that gingerol exerted dose-dependent and time-dependent growth inhibitory effects in these retinoblastoma cells. However, the growth inhibitory effects of gingerol were less pronounced against normal fr2 cells. As compared to the untreated control cells, gingerol-treated cells at concentrations of 25, 75, and 150 μM had drastic changes in cell morphology, including rounding and withering of cells, with disorganized cell layers. Gingerol-treated cells exhibited bright fluorescence, indicating rupture of the cell membrane. These results were further confirmed by acridine orange/propidium iodide staining, in which untreated cells showed normal green fluorescence and gingerol-treated cells showed yellow/red fluorescence. Gingerol also led to dose-dependent G2/M phase cell cycle arrest in RB355 retinoblastoma cells, as well as concentration-dependent activation of PI3K-related protein expressions.

Conclusions

Gingerol exhibits potent anticancer effects in RB355 human retinoblastoma cancer cells and these effects were mediated via apoptosis induction, cell cycle arrest, and modulation of the PI3K/Akt signaling pathway.

Orbital retinoblastoma: An update

Orbital extension is a major cause of death in children with retinoblastoma in the developing countries. Delayed detection and inappropriate management contribute to poor outcome. Conventional treatment including primary orbital exenteration or chemotherapy or radiotherapy alone result in mortality as high as 70%. The recent understanding on the role of sequential multimodal therapy with a combination of high-dose chemotherapy, followed by appropriate surgery, radiotherapy, and additional adjuvant chemotherapy has helped dramatically improve life salvage.

Quercetin inhibits angiogenesis-mediated human retinoblastoma growth by targeting vascular endothelial growth factor receptor

Retinoblastoma (RB) is the most common malignant intraocular cancer in teenagers, occurrence of which depends on the mutation of multiple genes. Among all the signaling pathways involved in the oncogenesis of RB, the process of angiogenesis has been demonstrated to be associated with the local invasive growth and metastasis of this cancer type. Quercetin (Que) is a typical flavonoid and has been reported to inhibit angiogenesis in various types of tumors. In the present study, the effect of Que on RB cells and angiogenesis of RB was evaluated. The human RB Y79 cell line was subjected to treatment with Que of various concentrations. Viability, invasion and migration ability and apoptosis of Y79 cells were subsequently measured to assess the effect of Que on RB cells. In addition, the expression of vascular endothelial growth factor receptor (VEGFR) was also quantified. It was revealed that Que inhibited RB cell growth and invasion in vitro in a dose-dependent manner, with 100 µM Que exhibiting the strongest inhibitory effect. In addition, Que downregulated the expression of VEGFR, which was an indicator of the blockade of angiogenesis in RB by targeting VEGF. The effect of Que on angiogenesis was also observed to be dose-dependent. The results of the present study indicated that Que may be a potential anti-RB therapy due to its anti-angiogenesis effect.

Retinoblastoma: A Sixteen-Year Review of the Presentation, Treatment, and Outcome from a Tertiary Care Institute in Northern India

Purpose

To study epidemiology, demographic profile, clinical characteristics, and outcome in pediatric patients with retinoblastoma.

Methods

This was a retrospective review of retinoblastoma patients of a tertiary institute from January 1st 1998 to December 31st 2014.

Results

The study included 467 patients (618 eyes) with a mean age of 34.7 ± 24.6 months (median = 30; 15 days to 144 months). Retinoblastoma was bilateral in 151 (32.3%) and there were 61.7% males. Intraocular disease was seen in 301 patients (451 eyes [72.9%]) and extraocular in 166 patients (167 eyes; 27.0%). Out of the 347 (74.3%) who received treatment, primary treatment was chemoreduction in 228 (65.7%) and enucleation in 117 (33.7%), while 25.6% of patients refused treatment and 151 (43.5%) defaulted therapy. Local recurrence was seen in 20 (4.3%), metastasis in 2 (0.4%), and deaths in 13 (2.8%) (average follow-up 28.5 ± 44.4 months). Histopathological high risk features were significantly less in the eyes that received chemoreduction (5.0%) versus primary enucleation (20.8%) (p < 0.0004), but there was no difference in the rate of metastasis, recurrence, and death between the two.

Conclusions

The majority of retinoblastoma patients in our study had advanced disease, and nearly a third had extraocular extension. There were a significant number of therapy refusals and dropouts. Chemoreduction led to a significant decrease in the histopathological risk factors without affecting the outcomes.

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.

Outcomes and complications after phacoemulsification in retinoblastoma patients with cataract after radiation treatment

PURPOSE

To describe the visual outcome and complications associated with phacoemulsification in patients with bilateral retinoblastoma (Rb), with lens opacification secondary to external beam radiotherapy.

METHODS

A descriptive study was performed on patients with Rb, treated in Federico Gomez Children's Hospital, Mexico, from January 1997 to August 2015, with external beam radiotherapy eye salvaging. Statistical analysis was performed using Stata 10.

RESULTS

A total of 15 patients were included. The mean age at phacoemulsification was 7.5 years. Mean preoperative visual acuity was 1.0LogMAR (range 0.4-1.6), and the mean postoperative visual acuity was 0.7LogMAR (range 0.1-1.6). Twelve patients had visual improvement (P<.05). The visual acuity decreased in one patient with vitreous haemorrhage and secondary glaucoma, and 2 patients with exudative maculopathy secondary to radiation. Mean follow up was 46 months and not a single patient showed tumour re-activation.

CONCLUSIONS

Cataract surgery produces a statistically significant improvement in visual acuity. These patients have increased risk for eye complications in the mid- and long-term. It is important to conduct a close follow up due to reactivation of tumour.

Extra-ocular retinoblastoma: about 12 cases followed at the Mohamed VI university hospital of Marrakech

Retinoblastoma is the most frequent childhood intraocular tumor. The aim of our study is to evaluate the clinical features and management of extra-ocular retinoblastoma in the Mohamed VI university hospital of Marrakech. Retrospective case series, the patient's records were reviewed for patient and tumor features, ocular management, histopathological findings, and patient survival. Over a period of three years, 35 eyes were diagnosed with retinoblastoma; 12 children (16 eyes) (46%) had extra-ocular retinoblastoma. Mean age was 27 months, 60% were males. Six cases had unilateral tumor, five bilateral and one case of trilateral retinoblastoma. There was no positive family history, proptosis was the mean mode of presentation (41,6%) followed by staphyloma (25%) orbital cellulitis (25%) and hyphema(8,3%). The median lag period was 18 months. On imaging and histopathological analysis, there was extrascleral involvement in 41.6%, involvement of orbital part of optic nerve (75%), of orbital muscles (50%) and eyelids in 16.6%. the surgical treatment included according to the degree of extension enucleation (75%) or exenteration (25%) associated to chemotherapy in all cases and one case of external beam radiation. There were 2 cases of orbital recurrence, one death and no metastases at 30 months follow-up.Orbital retinoblastoma still stands as a tall challenge requiring multi-modal and multi-disciplinary approach. Although the survival has increased over the last few years, lack of access to medical facilities, lack of education about the need for early medical attention and cultural resistance to enucleation continue to contribute to an epidemic of extra ocular disease at diagnosis in the developing world.

Maternal and Birth Characteristics and Childhood Embryonal Solid Tumors: A Population-Based Report from Brazil

BACKGROUND

Several maternal and birth characteristics have been reported to be associated with an increased risk of many childhood cancers. Our goal was to evaluate the risk of childhood embryonal solid tumors in relation to pre- and perinatal characteristics.

METHODS

A case-cohort study was performed using two population-based datasets, which were linked through R software. Tumors were classified as central nervous system (CNS) or non-CNS-embryonal (retinoblastoma, neuroblastoma, renal tumors, germ cell tumors, hepatoblastoma and soft tissue sarcoma). Children aged <6 years were selected. Adjustments were made for potential confounders. Odds ratios (OR) with 95% confidence intervals (CI) were computed by unconditional logistic regression analysis using SPSS.

RESULTS

Males, high maternal education level, and birth anomalies were independent risk factors. Among children diagnosed older than 24 months of age, cesarean section (CS) was a significant risk factor. Five-minute Apgar ≤8 was an independent risk factor for renal tumors. A decreasing risk with increasing birth order was observed for all tumor types except for retinoblastoma. Among children with neuroblastoma, the risk decreased with increasing birth order (OR = 0.82 (95% CI 0.67-1.01)). Children delivered by CS had a marginally significantly increased OR for all tumors except retinoblastoma. High maternal education level showed a significant increase in the odds for all tumors together, CNS tumors, and neuroblastoma.

CONCLUSION

This evidence suggests that male gender, high maternal education level, and birth anomalies are risk factors for childhood tumors irrespective of the age at diagnosis. Cesarean section, birth order, and 5-minute Apgar score were risk factors for some tumor subtypes.

An extremely rare case of metastatic retinoblastoma of parotids presenting as a massive swelling in a child

Retinoblastoma (Rb) is a common childhood malignancy but bilateral Rb with metastasis to parotids is very uncommon. To the best of our knowledge, bilateral Rb metastasizing to parotids is very rare and this is the fifth such case reported in world literature till date in a 2-year-old male child who underwent exenteration of left eye for bilateral Rb and later developed recurrent metastasis to left parotid requiring parotidectomy. A year later he presented again with swelling left parotid region extending from occipital region reaching upto left anterior chest wall with intra-cranial extension on magnetic resonance imaging. Histopathological examination of the parotid swelling and immunohistochemistry showed metastasis from Rb. He was treated with chemotherapy followed by radiotherapy to local site and brain to which he responded well. Presently on regular follow up without any signs of locoregional and distal metastasis. Till date different types of primary parotid tumors have been reported in literature but a metastatic parotid tumor is extremely rare and therefore this case is being reported to highlight the extreme rarity, the diagnostic and therapeutic challenges, the highly aggressive nature and overall dismal prognosis of this disease entity.

Incidence and survival of retinoblastoma in Taiwan: a nationwide population-based study 1998-2011

OBJECTIVE

To study the epidemiology of retinoblastoma in Taiwan from 1998 to 2011.

DESIGN

This was a retrospective population-based cohort study using the Taiwan National Health Insurance Research Database.

RESULTS

The present study included 154 patients (92 males, 62 females) with retinoblastoma and the documented overall retinoblastoma incidence was 1 in 17 373 live births without a notable trend over the study period. The incidence per million live births examined by gender was 65.8 for males and 48.5 for females. The age-specific sex ratio increased from 1.4 at age younger than 1 year to 3.0 above age 4 years. Enucleation was performed in 109 (70.8%) children with retinoblastoma, and it was more prevalent in males than in females (77.2% vs 61.3%, p=0.0335). Multivariate Cox regression analyses with adjustment for diagnostic age, sex, and birth year elucidated that enucleation was a significant factor associated with survival (OR 0.27, 95% CI 0.10 to 0.61).

CONCLUSIONS

The incidence of retinoblastoma in Taiwan exhibited no marked trend over time. There were more cases of males than females and the male-to-female rate ratio increased with age. Survival outcome was significantly associated with the intervention of enucleation.

Treating retinoblastoma in the first year of life in a national tertiary paediatric hospital in Mexico

AIM

Retinoblastoma is the most common primary ocular malignancy in childhood, but little has been documented on the clinical and biological differences in children diagnosed before one year of age. We observed patients in this age group and followed them for up to 19 years.

METHODS

This retrospective, descriptive, observational study reviewed the medical records of Mexican patients, who were diagnosed with retinoblastoma before one year of age at a national paediatric hospital from 1995 to 2014. The variables analysed were age at diagnosis, weight, presenting signs, the time from first symptoms to diagnosis, family history, laterality, ocular rescue and survival rate.

RESULTS

The 108 patients had a mean age of 7.65 months and 15.7% had a family history of retinoblastoma. The majority (55.5%) had bilateral retinoblastoma, the most common presenting sign was leukocoria (86.1%), and the most common stage of diagnosis was Group V (84.1%). More than half were underweight for their age. The overall survival rate was 92% and the disease-free survival rate was 84%.

CONCLUSION

Retinoblastoma is a malignancy that can be present at birth, especially if it is a bilateral hereditary form of the disease. Leukocoria was the main presenting sign. Early diagnosis dramatically improved the prognosis for ocular rescue.

Management of retinoblastoma: opportunities and challenges

Nano-delivery systems have significantly evolved over the last decade for the treatment of cancer by enabling site-specific delivery and improved bioavailability. The widely investigated nanoparticle systems are biodegradable polyesters, dendrimers, liposomes, mesoporous silica and gold nanoparticles. These particles when conjugated with different targeting motifs enhance the therapeutic efficiency of the drug molecules and biocompatibility. However, the application of such systems towards the treatment of retinoblastoma (RB), a rapidly spreading childhood eye cancer, still remains in its infancy. Nanoparticle-based systems that have been investigated for RB therapy have displayed improved drug delivery to the most restricted posterior segment of the eyes and have increased intra-vitreal half-life of the chemotherapy agents highlighting its potential in treatment of this form of cancer. This review focuses on the challenges involved in the treatment of RB and highlights the attempts made to develop nano-dimensional systems for the treatment of RB.

Retinoblastoma in Turkey: results from a tertiary care center in Ankara

PURPOSE

To evaluate the presentation patterns and results of management of retinoblastoma at a tertiary care center in Ankara, Turkey, with special emphasis on globe conservation rate in unilateral and bilateral intraocular retinoblastoma.

METHODS

Patients were grouped according to the International Classification of Retinoblastoma. For intraocular retinoblastoma, group E and some group D eyes underwent primary enucleation. Secondary enucleation was performed after failure of chemoreduction, focal treatments, external beam radiotherapy (EBRT), and intra-arterial chemotherapy used in various combinations. For extraocular retinoblastoma cases, treatment consisted of enucleation/exenteration or orbital biopsy, high-dose chemotherapy, and EBRT to the orbit and metastatic sites.

RESULTS

During the study period from October 1998 to May 2010, 165 of 192 (85.9%) patients had intraocular disease and 27 (14.1%) patients had extraocular disease. In total, primary or secondary enucleation was performed in 70 of 94 eyes with unilateral retinoblastoma (74.5%) and in 34 of 142 eyes with bilateral retinoblastoma (23.9%). The overall globe conservation rate was 69.6%. Only one patient in the intraocular retinoblastoma group died of metastatic retinoblastoma to the central nervous system. Twenty of 27 patients (74.1%) with extraocular retinoblastoma were found to have metastasis to the central nervous system, bone, bone marrow, and/or lymph nodes. At a mean follow-up of 28.0 months (median: 12 months; range: 1 to 120 months), survival was 33.3% despite intensive treatment.

CONCLUSIONS

The overall risk of enucleation was 75% in eyes with unilateral retinoblastoma and 24% in eyes with bilateral retinoblastoma. Extraocular retinoblastoma carries a 75% risk of systemic metastasis and 67% risk of death.