Retinoblastoma: problems and perspectives from India

Epidemiological and Clinical Presentation of Retinoblastoma among Nepalese Children in 2019

Suresh B.K. RasailyObjectives  Retinoblastoma (RB) is rare but potentially fatal if left untreated. This study aimed to evaluate the epidemiological profile, clinical manifestation, classification, and affordability of RB treatment among Nepalese children in the year 2019. Materials and Method  A multicentric, multiethnic hospital-based cross-sectional study after ethical approval from the National Health Research Council was conducted from January 2019 to December 2019 by incorporating ophthalmologists all over the nation. Twenty-seven RB centers were selected. All the RB presented in the RB centers either newly diagnosed or ongoing treatment consented to the study were included and failed to consent for the study, RB survivors were excluded from the study. Data based on demographic profile, clinical manifestation, ethnical and geographical distribution, and treatment received were collected in the customized Google Form. Each case was classified at the time of diagnosis as per the International Classification of Retinoblastoma groups and different treatment modalities offered as per grouping and staging. The affordability of treatment was calculated using a catastrophic approach. Statistical Analysis  Data were entered into Microsoft Excel 2010 and analyzed using Statistical Package for Social Sciences version 20. Result  A total of 34 RB cases, 21 (61.76%) in ongoing treatment group and 13 (38.2%) in newly diagnosed group presented in the RB centers. Out of total, 32 (64.7%) had unilateral and 12 (35.3%) cases had bilateral involvement. The majority of patients was from Province 1 (35.3%) and belonged to the upper caste (38.2%). Leukocoria was the most common presentation (73.9%) followed by proptosis, red eye, and phthisis bulbi. More than 75% patients presented at advanced group D (54%) and E (21%) and stage 0 (90%). More than 90% of patients received systemic chemotherapy, and 42.6% received transpupillary thermotherapy. The average cost of RB treatment was estimated to be 521% of the nonfood expense of the family which is unaffordable to almost all cases (100%). Conclusion  Leukocoria is the most common mode of clinical presentation in both unilateral and bilateral RBs. Early diagnosis and appropriate treatment are key to success for saving life, sight, and eye. However, community awareness programs against RB, active referral networks, and the establishment of chemotherapy centers with trained human resources are needed to reduce loss of life, sight, and eye.

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.

Correlation of clinical and radiological predictors of retinoblastoma with high-risk histopathological features

INTRODUCTION

Retinoblastoma (RB) tumors having high-risk histopathologic features (HRFs) have an increased risk of metastasis and disease relapse. However, RB has not been studied widely in Pakistan. Therefore, we evaluated the association of clinical, histopathologic, and radiological findings with HRFs in patients with RB who were treated at the Indus Health & Hospital Network in Karachi, Pakistan.

METHODS

We enrolled treatment-naïve patients with RB who received upfront enucleation from September 2017 to February 2021. We evaluated enucleated eyes with the Intraocular Classification of Retinoblastoma system and classified HRFs as invasion of the anterior chamber, including the iris and ciliary body, or massive invasion of the choroid, sclera, or optic nerve (postlaminar and/or up to the transection line).

RESULTS

Of 117 patients with RB treated at our institution during the study period, 54 received upfront enucleation. Unilateral disease was present in 92.6% of cases. The most frequent disease signs and symptoms included the presence of vitreous seeds (30.6%) and leukocoria (100%), respectively. The most frequent HRFs and radiological findings comprised massive choroidal invasion (15.1%) and anterior chamber enhancement (66.7%), respectively. The majority (62.9%) of patients did not exhibit any HRFs. Female sex, pseudohypopyon, iris neovascularization, buphthalmos, and glaucoma had significant predictive ability for HRF occurrence.

CONCLUSION

Pseudohypopyon, iris neovascularization, buphthalmos, and glaucoma are important clinical factors that should be taken into consideration before the management of RB. Early recognition of high-risk histopathological and radiological features is essential for appropriate treatment of RB.

Clinicoepidemiological Profile and Treatment Outcomes in Children with Retinoblastoma: Experience from a Cancer Care Center in Northeast India

Gaurav KumarBackground  Retinoblastoma (RB) is the most common primary intraocular malignancy in children. We sought to provide a comprehensive assessment of epidemiological profile and treatment outcomes of children with RB. Methods  In this retrospective study, we analyzed 189 children diagnosed with RB at our center between 2004 and 2017. Survival was analyzed with the Kaplan-Meier method and log-rank test. Results  Median age at presentation was 14 months with male: female ratio 1.2:1. Mean duration between onset of symptoms and presentation was 49 days (standard deviation ± 79). Most common presenting symptom was white pupillary reflex in 60% of children. Family history of RB and other cancers was found in one (0.5%) and seven (4%) children, respectively. Primary mode of diagnosis and staging was ocular ultrasonography (bone scan) in 87% of patients. Computed tomographic scan and magnetic resonance imaging were done in 124 (66%) and 30 (16%) patients, respectively. International staging system grade E disease was found in 144 (76%), extraocular disease in 55 (29%), bilateral disease in 49 (26%), and trilateral disease in 3 (1.5%) children. Out of 189 children with RB, 33 (18%) refused treatment and 156 children received treatment (24 children [15%] abandoned treatment midway and 132 [85%] completed treatment). One hundred children (64%) received systemic therapy as neoadjuvant or adjuvant chemotherapy and 20 (13%) received local therapy. Eyeball and vision salvage rate with chemotherapy were 20 (13%) and 9 (6%), respectively. Cryotherapy was the most common modality of local treatment used in 11 (55%) children. Five-year survival for patients who received treatment was 76% (median survival not reached). In the treatment refusal group, median survival was 9 months. Conclusion  In developing countries, RB is mostly detected in advanced stages resulting in poor outcomes. Increased awareness and accessibility to dedicated centers for treating childhood malignancy can lead to early diagnosis, better prognosis, and increased vision salvage.

Knowledge and awareness of the general population and healthcare providers about retinoblastoma: It is time to know the glow

Retinoblastoma is the most frequent primary intraocular tumour in childhood. Early detection of retinoblastoma is the key to successful management with a higher chance of survival. This study aims to assess the knowledge of the general population and healthcare providers about retinoblastoma in term of presentation, risk factors, timing for diagnosis, and complications. A cross-sectional study using an online survey was conducted in three Arab countries (Jordan, Saudi Arabia, and Iraq) between 28 August and 16 September 2020. The questionnaire tool was constructed based on an extensive literature review to explore the study's aim and objectives. Logistic regression was used to identify predictors of better knowledge about retinoblastoma. A total of 3676 participants were involved in the study (Jordan = 2654, Saudi Arabia = 604, and Iraq = 418). The average retinoblastoma knowledge score for the whole study population was 6.25 (SD = 4.12) out of 21, representing 29.8% (out of the maximum possible total score). Participants aged above 50 years old, married individuals, those with a secondary education level, those who work as professionals in industry, those who have more than four children, and those who reported that they were not in direct contact with a large number of children were less likely to be knowledgeable about retinoblastoma presentation, risk factors, the timing for diagnosis, and complications (P < .05). Early detection is the cornerstone for decreasing morbidity and mortality among children with retinoblastoma. However, the awareness and knowledge about retinoblastoma are very limited in our study population. Efforts should be directed at increasing awareness of both the general population and healthcare providers regarding retinoblastoma. Policymakers are responsible for improving knowledge and awareness about retinoblastoma to facilitate early detection of the disease by conducting awareness campaigns in addition to improve screening skills of healthcare providers and providing them with proper screening and diagnostic tools.

Different Types of Clinical Presentations and Stages of Retinoblastoma Among Children

Introduction

Retinoblastoma (Rb) is the most common intraocular malignant tumor of childhood. The different modes of Rb presentation comprise proptosis, anterior chamber inflammatory signs, spontaneous hyphema, secondary glaucoma, and strabismus. The primary aim of this study was to investigate the different clinical presentations and stages of Rb that may help in early detection and timely diagnosis to prevent the advancement of the disease and increase rates of survival in children. 

Materials and methods

This was a descriptive cross-sectional study conducted between December 2019 and May 2020 over a period of six months at a tertiary care hospital in Karachi, Pakistan. The sample size included 68 eyes of children with lesions of Rb at the time of presentation to the hospital. Brightness scans (B-scans), computed tomography (CT) scans, and magnetic resonance imaging (MRI) were performed. The International Intraocular Retinoblastoma Classification (IIRC) was used to stage each eye. In case of enucleation (if necessary) of the eye, the biopsy was performed to evaluate the histological features of cancer. All statistical analysis was performed using Statistical Package for Social Sciences version 17.0 (IBM Corp., Armonk, New York).

Results

The mean age of the children was 3.21 ± 1.75 years. Leukocoria was the most common clinical presentation observed in more than half (n = 35, 51.47%) of the sample population followed by proptosis reported in nearly two-fifths (n = 25, 36.76%), strabismus and phthisis bulbi observed in equal proportions (n = 3, 4.41%), and hypopyon documented in a minor proportion (n = 2, 2.94%) of patients. Regarding stages of the Rb disease, the most common stages were observed to be stage C and stage E. 

Conclusions

This study concludes that the early detection of Rb is possible through a better understanding of presenting features of the disease. It can prevent the progression of the disease to the advanced stages and decrease morbidity and mortality. The early detection of Rb can be made possible through the examination of red reflex on the regular check-ups of children as leukocoria is the most common clinical presentation.

Molecular evidence of human papillomaviruses in the retinoblastoma tumor

Retinoblastoma tumor (RB) is one of the most prevalent ocular cancers among children. RB may be caused by inherited mutations in RB1 gene as well as some environmental risk factors. Human papillomaviruses (HPV) are suspected as a risk factor of RB due to their pRb inactivating protein. This study evaluated the molecular prevalence of HPV among the RB tumor specimens in Iran. The RB tumor samples were tested for detection of HPV-L1 gene using a nested-PCR approach, and then followed by sequencing and phylogenetic analysis to reveal HPV types. Overall, there were 61 RB tumor samples; 54/61 (88.5%) had unilateral and 7/61 (11.5%) bilateral RB; 55/61 cases (90.2%) had sporadic non-familial RB tumor. HPV-DNA was detected in 6/61 (9.8%) of patients' tumors; the HPV positive RB cases all had unilateral and unfamiliar sporadic RB tumor. HPV type 16 was the most prevalent type identified across the RB tumor samples (3/61, 4.9%). The rate of detected HPV among the RB specimens seems to be considerable. Further investigations are required to elucidate the exact association between HPV and progression to RB.

HIGH-RISK INTRAOCULAR RETINOBLASTOMA: Comparison Between Asian Indians and Americans From Two Major Referral Centers

PURPOSE

To identify the differences in the clinical and histopathologic features in eyes with advanced intraocular retinoblastoma in a developing country (India) versus a developed country (USA).

METHODS

Retrospective study.

RESULTS

Of 524 patients with retinoblastoma who underwent primary enucleation, 331 were from India, and 193 were from the USA. Asian Indians were older at presentation (35 months vs. 29 months; P = 0.02), had thicker tumors (13.8 mm vs. 12.4 mm; P = 0.0001) compared with Americans. High-risk intraocular retinoblastoma was more common in Asian Indians with a 2-fold greater risk compared with Americans (35% vs. 23%; odds ratio = 1.83; P = 0.003). Statistically significant differences in the histopathologic features (Asian Indians vs. Americans) included massive (≥3 mm) choroidal infiltration (17% vs. 6%; P = 0.0003) and optic nerve infiltration (48% vs. 15%; P = 0.0001). Asian Indians had a 5-fold greater risk of having optic nerve invasion (odds ratio = 5.45; P < 0.0001) and 3-fold greater risk of massive choroidal invasion (odds ratio = 2.80; P < 0.0001) compared with Americans. With appropriate use of adjuvant systemic chemotherapy, the difference in the rates of systemic metastasis (5% vs. 2%, P = 0.67) and related death in both countries (5% vs. 0%, P = 0.14) were not statistically significant.

CONCLUSION

High-risk intraocular retinoblastoma is more common in Asian Indians compared with Americans.

Time to diagnosis of retinoblastoma in Latin America: A systematic review

Retinoblastoma (RB) is the most common intraocular tumor of childhood. In low income countries, Time to diagnosis (TTD: interval between first symptom and diagnosis) has been associated with extraocular disease, metastasis and mortality. However, the relationship between TTD and prognosis is complex and not simply a linear correlation, particularly if TTD is <6 months. This systematic review aims to identify studies reporting TTD of retinoblastoma in Latin America, highlighting factors affecting TTD, alongside proposals and initiatives to obtain shorter intervals. The review also aims to discuss the methodology linked to cancer pathways studies. The study respected PRISMA recommendations, was registered on Prospero, an international database for systematic review registries under number CRD42017076777. MEDLINE/PUBMED, LILACS and SCIELO databases were searched. Studies from Latin America and the Caribbean, published between 1997 and 2017, reporting TTD and age at diagnosis of patients with retinoblastoma were selected. Nine studies were selected, concerning 1560 patients from Argentina, Brazil, Chile, Honduras, Mexico and Peru. The median TTD ranged from 3 to 5 months and the median age at diagnosis ranged from 16.5 to 22.2 months. A prolonged TTD was observed and was associated to damaging results on retinoblastoma outcomes, particularly increasing extraocular disease, and mortality rates. Methodological heterogeneity was observed and reiterates the importance of standardization of TTD studies, allowing more reliable comparisons and greater knowledge about retinoblastoma pathways before diagnosis. Reports on successful initiatives against delayed diagnosis were scarce, emphasizing a need for further studies.

A Profile of Pediatric Solid Tumors: A Single Institution Experience in Kashmir

Aims:

The purpose of this retroprospective study was to study the epidemiological characteristics and outcomes of children with solid tumors at our institution.

Subjects and Methods:

Three hundred and three pediatrics patients registered at Regional Cancer Centre (RCC), Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Kashmir, between January 2008 and June 2014, were analyzed with regard to demographic status, presenting complaints, investigations, treatment, morbidity, and outcomes. Standard statistical methods were used for analysis.

Results:

Among 19,880 patients registered at RCC, SKIMS from January 2008 till June 2014, 986 (4.9%) were of pediatric age group. Of these, 303 (30.7%) patients had pediatric solid tumors. The male-to-female ratio was 1.04, there were no infants (up to 27 days), 6% were infants and toddlers (28 days–23 months), 39% were children (2–11 years), and 55% were adolescents (12–19 years). There were 86% rural patients and 14% urban patients. Most common were central nervous system tumors (25.74%), followed by germ cell tumors (14.52%), primitive neuroectodermal tumor/Ewing sarcoma (13.86%), Wilms' tumor (8.9%), osteosarcoma (6.6%), rhabdomyosarcoma (5.6%), colorectal cancer (5.28%), neuroblastoma (4.9%), and retinoblastoma (2.6%). Outcomes: 33.9% patients went into remission, 35.64% were defaulters, 2.97% had stable disease, 2.31% had partial response, 20.79% expired, and 3.96% were still on treatment. Of all these patients, 5.28% had a relapse.

Conclusions:

Across the series, advanced stage of presentation, a high incidence of default and poor follow-up was seen. Multiple interrelated factors are responsible for the poorer outlook of childhood cancer in Kashmir.

Epidemiological Characteristics of Retinoblastoma in Children Attending Almouassat University Hospital, Damascus, Syria, 2012-2016

Retinoblastoma (Rb) is a malignant tumor that originates from the developing retina. Diagnosis is based on clinical signs and symptoms and usually children under the age of five years are affected. Early diagnosis and treatment of Rb and non-ocular tumors can reduce morbidity and increase longevity. Treatment in the early stages may allow a good prognosis and salvage of visual function.The aim of this study is to present descriptive epidemiological aspects of retinoblastomas in children seen at Almouassat University Hospital (AUH) in Damascus, Syria from 1 January 2012 to 31 October 2016In this retrospective, observational hospital survey, medical records of 37 retinoblastoma cases were reviewed. The male/female (M/F) ratio was 1.6. The most frequent presenting sign was leukocoria (56.7%) and 81% of cases were diagnosed between the ages of 4 months and 3 years. More than 73% of cases were diagnosed early at stages I and II.

HPV-16 Detected in One-Fourth Eyes With Retinoblastoma: A Prospective Case-control Study From North India

The incidence of nonfamilial retinoblastoma (RB) is believed to be higher in developing countries. The reports on association of human papillomavirus (HPV) with RB are limited and contradictory. The aim was to investigate the prevalence of HPV in RB tumor tissue. In the prospective study, consecutive eyes enucleated for RB from patients lacking a family history of RB were enrolled as cases over a 3-year period. Controls included donor eyes obtained from the eye bank. Normal retinal tissue from the donor eyes and tumor tissue from eyes with RB was subjected to DNA isolation. Polymerase chain reaction followed by dot-blot hybridization was performed to detect 21 HPV genotypes. The study cohort included 39 RB and 42 normal retinal tissues. A positive result for HPV-polymerase chain reaction was obtained in 10 (25.6%) tumor tissues and none of the control eyes. HPV-16 was the only subtype detected. Socioeconomic status (P=0.58) or maternal age (P=0.58) was not associated with presence of HPV. All HPV-positive patients had undergone a vaginal delivery (P=0.60). HPV-16 was detected in one-fourth cases of nonfamilial RB. None of the control cases (donor eyes) tested positive. Implication of the presence of HPV in RB tissue and role in carcinogenesis needs further elucidation.

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.

Paediatric retinoblastoma in India: evidence from the National Cancer Registry Programme

BACKGROUND

Globally, retinoblastoma is the most common primary intraocular malignancy occurring in children. This paper documents the recent incidence rates of retinoblastoma by age and sex groups from the Population Based Cancer Registries (PBCRs) of Bangalore, Mumbai, Chennai, Delhi and Kolkata using the data from the National Cancer Registry Programme.

MATERIALS AND METHODS

Relative proportions, sex ratio, method of diagnosis, and incidence rates (crude and age standardized) for each PBCR and pooled rates of the five PBCRs were calculated for the years 2005/06 to 2009/10. Standard errors and 95% confidence limits of ASIRs by sex group in each PBCR were calculated using the Poisson distribution. Standardised rate ratios of ASIR by sex group and rate ratios at risk were also calculated.

RESULTS

The maximum retinoblastoma cases were in the 0-4 age group, accounting for 78% (females) and 81% (males) of pooled cases from five PBCRs. The pooled crude incidence rate in the 0-14 age group was 3.5 and the pooled ASIR was 4.4 per million. The pooled ASIR in the 0-4, 5-9 and 10-14 age group were 9.6, 2.0 and 0.1 respectively. The M/F ratio in Chennai (1.9) and Bangalore PBCRs (2.0) was much higher than the other PBCRs. Among the PBCRs, the highest incidence rate in 0-4 age group was found in males in Chennai (21.7 per million), and females in Kolkata (18.9 per million). There was a distinct variation in incidence rates in the PBCRs in different geographic regions of India.

Presentation of retinoblastoma patients in Malaysia

BACKGROUND

Retinoblastoma is a rare type of cancer that usually develops in early childhood. If left untreated it can cause blindness and even death. The aim of this study is to determine sociodemographic and clinical features of retinoblastoma patients and also to determine the treatment pattern and outcome in Malaysia.

MATERIALS AND METHODS

Data for this study were retrieved from the Retinoblastoma Registry of the National Eye Database (NED) in Malaysia. Hospital Kuala Lumpur, Hospital Umum Kuching, Sarawak and Hospital Queen Elizabeth, Kota Kinabalu were the major source data providers for this study. Data collected in the registry cover demography, clinical presentation, modes of treatment, outcomes and complications.

RESULTS

The study group consisted of 119 patients (162 eyes) diagnosed with retinoblastoma between 2004 and 2012. There were 68 male (57.1%) and 51 (42.9%) female. The median age at presentation was 22 months. A majority of patients were Malays (54.6%), followed by Chinese (18, 5%), Indians (8.4%), and indigenous races (15.9%). Seventy six (63.8%) patients had unilateral involvement whereas 43 patients had bilateral disease (36.1%). It was found that most children presented with leukocoria (110 patients), followed by strabismus (19), and protopsis (12). Among the 76 with unilateral involvement (76 eyes), enucleation was performed for a majority (79%). More than half of these patients had extraocular extension. Of the 40 who received chemotherapy, 95% were given drugs systemically. Furthermore, in 43 patients with bilateral involvement (86 eyes), 35 (41%) eyes were enucleated and 17 (49%) showed extraocular extension. Seventy-two percent of these patients received systemic chemotherapy. The patients were followed up 1 year after diagnosis, whereby 66 were found to be alive and 4 dead. Sixteen patients defaulted treatment and were lost to follow-up, whereas follow-up data were not available in 33 patients.

CONCLUSIONS

Patients with retinoblastoma in this middle-income Asian setting are presenting at late stages. As a result, a high proportion of patients warrant aggressive management such as enucleation. We also showed that a high number of patients default follow-up. Therefore, reduction in refusal or delay to initial treatment, and follow-up should be emphasized in order to improve the survival rates of retinoblastoma in this part of the world.

Identification and Insilico Analysis of Retinoblastoma Serum microRNA Profile and Gene Targets Towards Prediction of Novel Serum Biomarkers

Retinoblastoma (RB) is a malignant tumor of the retina seen in children, and potential non invasive biomarkers are in need for rapid diagnosis and for prognosticating the therapy. This study was undertaken to identify the differentially expressed miRNAs in the serum of children with RB in comparison with the normal age matched serum, to analyze its concurrence with the existing RB tumor miRNA profile, to identify its novel gene targets specific to RB, and to study the expression of a few of the identified oncogenic miRNAs in the advanced stage primary RB patient’s serum sample. MiRNA profiling was performed on 14 pooled serum from children with advanced RB and 14 normal age matched serum samples, wherein 21 miRNAs were found to be upregulated (fold change ≤ −2.0, P ≤ 0.05) and 24 to be downregulated (fold change ≥ +2.0, P ≤ 0.05). Furthermore, intersection of 59 significantly deregulated miRNAs identified from RB tumor profiles with that of miRNAs detected in serum profile revealed that 33 miRNAs had followed a similar deregulation pattern in RB serum. Later we validated a few of the miRNAs (miRNA 17-92) identified by microarray in the RB patient serum samples (n = 20) by using qRT-PCR. Expression of the oncogenic miRNAs, miR-17, miR-18a, and miR-20a by qRT-PCR was significant in the serum samples exploring the potential of serum miRNAs identification as noninvasive diagnosis. Moreover, from miRNA gene target prediction, key regulatory genes of cell proliferation, apoptosis, and positive and negative regulatory networks involved in RB progression were identified in the gene expression profile of RB tumors. Therefore, these identified miRNAs and their corresponding target genes could give insights on potential biomarkers and key events involved in the RB pathway.

Retinoblastoma in Central America: report from the Central American Association of Pediatric Hematology Oncology (AHOPCA)

BACKGROUND

Retinoblastoma is highly curable in high income countries. Low income countries have poor results due to advanced disease and lack of resources. Central American Association of Pediatric Hematology Oncology (AHOPCA) aimed to standardize the approach and to improve outcomes of patients with retinoblastoma.

PROCEDURE

One hundred seventy-one patients, age <18 years newly diagnosed with retinoblastoma were treated according to laterality and stage. Therapeutic modalities were: surgery (enucleation), local control (laser therapy, cryotherapy), chemotherapy, and radiation therapy. Chemotherapy consisted of vincristine, etoposide, and carboplatin (6 cycles). Outcomes were measured by overall survival. Events were abandonment of therapy and death.

RESULTS

One hundred seventy-one patients (129 unilateral, 42 bilateral) were treated. Median age was 2 years 4 months; 112 (66%) were diagnosed before 3 years of age. 119 (92%) eyes in patients with unilateral disease were Reese-Ellsworth IV or V versus 52 (62%) eyes in patients with bilateral disease. Extraocular disease was more prevalent in unilateral disease (65% vs. 50%). Older age at diagnosis correlated with higher stage. Estimated overall survival at 60 months was 0.48 ± 0.04. Outcome of patients with bilateral disease was significantly better than unilateral (62% ± 0.09 vs. 42% ± 0.05, P = 0.0006). Thirty-eight patients (22%) refused or abandoned therapy.

CONCLUSIONS

Protocol-directed therapy for retinoblastoma in Central America is possible. Patients present with advanced disease and outcome is significantly worse than in middle and high-income countries. Refusal and abandonment of therapy are societal events that affect outcome. Initiatives aimed at improving early diagnosis, while dedicated treatment centers are developed, are critical.

Evidence for the presence of high risk human papillomavirus in retinoblastoma tissue from nonfamilial retinoblastoma in developing countries

BACKGROUND

The prevalence of human papillomavirus (HPV) infection in India is high. HPV infection is known to cause cervical cancer and has also been implicated in the pathogenesis of retinoblastoma (RB), a common intraocular malignant tumor of childhood which can be familial or sporadic. Despite the high incidence of RB in India, its familial form is rare. Hence this study was undertaken to investigate whether high-risk HPV types 16 and 18 are involved in the development of RB.

METHODS

Formalin fixed paraffin embedded RB tissues (n = 76) including prospective cases with corresponding maternal cervical smears (n = 10) were analyzed for the presence of HPV DNA sequences. Expression of the cell cycle regulatory proteins viz; p105, p107, p30, p16, E2F-1, E2F-4, and MiB-1 was studied by immunohistochemistry (IHC) (n = 34).

RESULTS

A total of 53 out of 76 (69.7%) cases were positive for HPV, of these 3 cases were positive for HPV-16, 23 for HPV-18, and 27 for both HPV-16 and -18. Of the prospective cases (n = 10) studied, five cases along with the corresponding maternal cervical cytology smear had identical HPV status. HPV-16 positive tumors were classified as well differentiated (P = 0.013). Nuclear expression of pRB2/p130 showed significant association with HPV-16 infection (P = 0.04) or dual infection of HPV-16/-18 (P = 0.02).

CONCLUSIONS

Our study lends support to the hypothesis that infection of HPV-16/-18 may play an important role in the development of nonfamilial form of RB in children in India.

Differential expression of genes in retinoblastoma

Retinoblastoma is a pediatric eye tumor that serves as a paradigm for understanding the genetic basis of cancer. Mutations and/or epigenetic alterations inactivating both alleles of the retinoblastoma gene (RB) are associated with retinoblastoma. There are many other genes which express differentially in the preneoplastic retinal cells after RB loss, as cells progress to form tumors. These genetic changes and the pathways involved can provide valuable insight into the development and progression of this cancer. Conventional molecular and genetic methods for studying cancer are limited to the analysis of one locus at a time. A cluster of genes that are regulated together can be identified by DNA microarray, and the functional relationships can uncover new aspects of cancer biology. Meta analysis is an important tool for the identification and validation of differentially expressed genes to increase power in clinical and biological studies across different sets of data. Recently, meta analysis approaches have been applied to large collections of microarray datasets to investigate molecular commonalities of multiple cancer types not only to find the common molecular pathways in tumor development but also to compare the individual datasets to other cancer datasets to identify new sets of genes. The outcome of these analyses might accelerate the application of basic research findings into daily clinical practice through translational research and may have an impact on foreseeing the clinical outcome, predicting tumor response to specific therapy, identification of new prognostic biomarkers, discovering targets for the development of novel therapies and providing further insights. These and related research efforts reveal novel data that enhance our understanding of the biology of retinoblastoma. These observations may facilitate new therapeutic approaches to further decrease the morbidity and mortality associated with retinoblastoma and other more common forms of cancer.

Clinical presentation of retinoblastoma in Malaysia: a review of 64 patients

AIM

To analyze the demography, presenting clinical features, spread of the disease of retinoblastoma in patients who were treated in two tertiary hospitals in Malaysia.

METHODS

In this retrospective study, information of gender, age, race, presenting clinical features, findings of CT scan orbits and brain, lumbar puncture and bone marrow aspiration results were collected from the medical records of retinoblastoma patients diagnosed in Hospital of Universiti Sains Malaysia and General Hospital of Kuala Lumpur over a period of ten years. The data were collected in the same type of proforma from both hospitals.

RESULTS

A total of 64 patients were treated in both hospitals together, of whom boys and girls were almost equally affected. The mean age of children at presentation was 24.2 (range 3-84) months, 53 (82.8%) children were under 36 months old. The disease was unilateral in 39 (60.9%) patients. The most common presenting signs were leukocoria in 46 (71.8%), followed by proptosis in 21 (32.8%) patients. Routine screening of the siblings of affected children revealed retinoblastoma in 2 patients. There was intracranial extension in 8 (12.5%) and metastasis in bone marrow in 6 (9.3%) patients.

CONCLUSION

Leukocoria is the most common presentation of retinoblastoma in Malaysia. However, the disease was intraocular in 40 (62.5%) and extraocular (orbital involvement, intracranial and distant metastasis) in 24 (37.5%) patients.

Orbital space-occupying lesions in Indian children

PURPOSE

To present a review of all patients younger than 16 years who presented to us with orbital space-occupying lesions.

METHODS

Retrospective case study.

RESULTS

We analyzed the records of 119 children younger than 16 years of age who had presented to us with proptosis during the 10-year study period. Myogenic tumors were the most common lesion seen (24%), followed by metastatic and secondary orbital tumors (17%), vasculogenic lesions (15%), cystic lesions (10%), inflammatory lesions simulating tumors (7.5%), optic nerve and meningeal tumors (7.5%), peripheral nerve tumors (5%), lacrimal fossa lesions (4%), lymphoid tumors and leukemias (2.5%), primitive neuroectodermal tumors (3%), and others (2.5%).

CONCLUSION

We analyzed the profile of orbital lesions that underwent surgical procedures and were proven histopathologically. We found 63 malignancies among the 119 cases, for a malignancy rate of 53%. Orbital rhabdomyosarcoma and retinoblastoma with orbital spread were the most common causes of proptosis among the children.

The study of c-Src kinase and pStat3 protein expression in retinoblastoma

We examine the immunoreactivity of the non-receptor tyrosine kinase, c-Src kinase and its downstream molecule, signal transducer and activator of transcription 3 (pStat3) in retinoblastoma (RB), and correlation with invasiveness and differentiation. Tumor samples from 40 patients with RB were available for the study. There were 18 tumors in group 1 (non-invasive) and 22 tumors in group 2 (invasive). The immunoreactivity of c-Src kinase and pStat3 was compared in the two groups of tumors. Group 1 (non-invasive) RB showed intermediate c-Src kinase immunoreactivity (Allred score 4-5) in 14/18 tumors and low immunoreactivity (Allred score 2-3) in 4/18 tumors. pStat3 was intermediate (Allred score 4-5) in 6/18 tumors and negative (Allred score 0) in 12/18 tumors. Group 2 (invasive) RB showed high c-Src kinase immunoreactivity (Allred score 6-8) in 22/22 tumors and high pStat3 (Allred score 6-8) in 19/22 tumors. The expression of c-Src kinase (P<0.001) and pStat3 (P<0.001) was significantly higher in group 2 RB. Src kinase expression (P<0.05) and pStat3 expression (P<0.05) was higher in the poorly differentiated tumors compared to moderately- and well-differentiated tumors. The increased expression of c-Src kinase and pStat3 expression could play a role in the invasiveness of group 2 tumors. Further characterization of the pathways involved in the pathogenesis of RB will shed light on fundamental mechanisms of tumorigenesis.

The clinical spectrum and treatment outcome of retinoblastoma in Indian children

PURPOSE

To study the clinical spectrum and treatment outcome of retinoblastoma in Indian children.

PATIENTS AND METHODS

This retrospective study analyzed 488 eyes of 355 retinoblastoma patients treated at a tertiary care ophthalmic hospital in southern India during a 14-year period.

RESULTS

Retinoblastoma involved one eye in 177 (50%) and both eyes in 178 (50%) patients. Mean age at presentation was 23.98 +/- 23.37.

A multicentre report from the Mexican Retinoblastoma Group

BACKGROUND

Retinoblastoma (RB) is a relatively uncommon tumour in childhood. The incidence of retinoblastoma in Mexico is probably higher than the incidence reported worldwide, however there is not enough information about the characteristics of this illness in Mexico. This report aims to present the results of a multicentre clinical survey of RB in Mexico.

METHODS

A retrospective study was carried out on all RB cases treated in 16 institutions during the last six years. The variables analysed were age at diagnosis, sex, affected eyes, treatment modalities, and pathological staging. Overall survival was obtained.

RESULTS

The authors analysed 500 cases; age range was 0-182 months. There were 364 unilateral cases (72.8%). Enucleation was performed in 84.9% of the patients. The St Jude's staging was: 7.4% stage I, 52.8% stage II, 18.0% stage III, 11.4% stage IV, 7.2% not evaluated, and 3.2% missing data. Chemotherapy was used in 74.4% of the patients. Disease free survival was 89% at 73 months follow up.

CONCLUSIONS

The paper presents a great number of cases and pioneers multicentre studies in paediatric ophthalmology and oncology in this country. Given the great number of patients in advanced stages and the variability on treatment schemes, it is evident that it is mandatory to work in a cooperative group and develop a national early detection programme as well as a treatment protocol which include all specialists involved in the care of patients with RB.

Primary malignant tumours of eye and adnexa in Eastern Nepal

BACKGROUND

The purpose of the present paper was to report the spectrum of primary malignant tumours of eye and adnexa at BP Koirala Institute of Health Sciences, Nepal, from 1995 to 2000.

METHODS

A retrospective study of medical records with histopathological confirmation of malignant tumours of the eye and adnexa was done for the years 1995-2000. A total of 116 consecutive medical records from the Department of Pathology at BP Koirala Institute of Health Sciences were retrieved. All those patients with primary ophthalmic malignancies were included and non-malignant cases were excluded.

RESULTS

There were 80 patients of which 39 (48.8%) were male and 41 (51.2%) were female. Four patients had bilateral involvement. The most common malignancy was retinoblastoma (45.2%), followed by basal cell carcinoma (22.6%).

CONCLUSION

Retinoblastoma is the most common eye cancer. The incidence of melanomas is correspondingly lower than that reported in the West. The present pilot study, the first of its kind, will lay the foundation for the monitoring of the future pattern of ophthalmic malignancies in Nepal and provide a basis for comparison elsewhere.

Histopathologic analysis of 232 eyes with retinoblastoma conducted in an Indian tertiary-care ophthalmic center

PURPOSE

To study the histopathologic features of 232 enucleated eyes with retinoblastoma.

MATERIALS AND METHODS

Two hundred thirty-two enucleated eyes with retinoblastoma in a tertiary-care institute from 1982 to 2001 were reviewed. Data were collected and analyzed about the type of growth and the presence or absence of vitreous or subretinal seeding, rosettes and fleurettes, necrosis, calcification, iris neovascularization, and invasion of the anterior chamber, iris, choroid, optic nerve, and sclera. Choroidal invasion was graded using a new system. Results were analyzed for statistical significance.

RESULTS

The endophytic growth pattern was common in 118 (51%) of the eyes. Vitreous seeds were present in 109 (47%) of the tumors, 23 (10%) of the tumors had subretinal seeds, and 14 (6%) of the tumors had both. Poorly differentiated tumors were present in 134 (58%) of the eyes. Iris neovascularization was noted in 71 (31%) of the eyes and choroidal invasion was observed in 78 (34%) of the eyes. Of these 78 eyes, full-thickness (stage 4) choroidal invasion was present in 51 (65%). Optic nerve invasion was observed in 75 (32%) of the eyes, of which prelaminar involvement occurred in 40 (53%) and postlaminar involvement occurred in 22 (29%).

CONCLUSION

A higher incidence of choroidal and optic nerve infiltration was noted among Asian Indian children than among children from the West. This could be due to delayed diagnosis or to a difference in the biological behavior of tumors occurring in the Asian Indian population.

Mutational analysis of the RB1 gene in Indian patients with retinoblastoma

Twenty-one probands, twelve with bilateral and nine with unilateral retinoblastoma, were screened for mutations in the RB1 gene using genomic DNA from peripheral blood leukocytes as well as tumors. Amplification of individual exons and flanking regions of the RB1 gene were carried out, followed by direct sequencing of the amplified products. Sequences of affected individuals were compared with those of controls. Mutations were identified in seven patients, five with bilateral and two with unilateral retinoblastoma. Six out of seven mutations involved the formation of premature termination codons by means of single base substitutions (2), frameshifts due to splice-site mutations (2), or deletion and duplication (2). One missense mutation was identified. Of the remaining fourteen patients, seven with bilateral disease had no mutations in peripheral blood (7 cases) or tumors (3/7 cases). Analysis of the peripheral blood of seven patients with unilateral disease also showed no mutations. Mutations were detected in about one-third of the cases, suggesting that hemizygous deletions at the RB1 locus or mutations outside the coding regions of RB1 may be responsible for the disease in the remaining patients.

Enucleation in a tertiary eye care centre in India: prevalence, current indications and clinicopathological correlation

PURPOSE

Enucleation is a standard surgical treatment modality for many end-stage eye diseases. Indications for enucleation vary with changing trends in disease management. Few studies have addressed the issue of the frequency and indications of enucleation of eyes in India. We aimed to determine the frequency and the current clinical indications for enucleation in patients at a tertiary eye care centre in India, and attempted a clinicopathological correlation.

METHODS

Medical records of patients undergoing enucleation at a tertiary eye care centre over a period of 3 1/2 years (January 1995 to July 1998) were reviewed to obtain patients' demographic data and socio-economic status. The clinical indications and predisposing factors were assessed. The formalin-fixed, paraffin-embedded sections of all enucleated eyes were re-evaluated and histopathological findings were correlated with the clinical diagnosis. The prevalence of enucleation was calculated, and age adjustments were done using the Indian population data from 1998 mid-year statistics.

RESULTS

Enucleation of the eye was performed in 150 patients (151 eyes) out of 88,991 new ophthalmic cases, constituting 0.17% of the cases seen in the hospital, and amounting to a prevalence of 0.33% (95% CI, 0.27-0.40). Males outnumbered females in a ratio of 1.85:1 (98 males, 53 females). The median age was 8 years (mean 16.8 +/- 18.3 years). Children below 15 years of age constituted 85.2% (95% CI, 81.2-89.21%) of cases that underwent enucleation. Clinical indications for enucleation included tumours in 74 (49%); staphyloma in 38 (25%); acute injury in 20 (13%); absolute glaucoma in 9 (6%); painful blind eye in 5 (3%); phthisis bulbi in 1 (1%); and others in 4 (3%). Of the 74 cases with a clinical diagnosis of tumour, histopathology revealed retinoblastoma in 55 (74%) cases, melanoma in 6 (8%) and ocular surface tumours in 4 (6%). Clinico-pathological correlation was 100% in cases with a definite clinical diagnosis of retinoblastoma and melanoma. Nine blind eyes (6%) in which an intraocular tumour was one of the differential diagnoses, were negative for a tumour on histopathology. Staphyloma was more prevalent in the low socio-economic group (p = 0.0004), with a history of childhood trauma in 34% cases.

CONCLUSIONS

The prevalence of enucleation in the population reporting to this tertiary eye care centre was 33 per 10,000 population over the study period of 3 1/2 years. Major indications for enucleation were tumours, staphyloma and trauma (88% of all cases). Increased frequency in the young was due to the high proportion of retinoblastoma and staphyloma. Childhood trauma, inflammation and malnutrition may together play a role in the pathogenesis of staphyloma. Awareness at the level of primary health care providers, paediatricians and general practitioners should be promoted to identify the disease process at an early stage and facilitate early intervention measures that could result in eye and vision salvage.

Metastatic and nonmetastatic models of retinoblastoma

To generate animal models of retinoblastoma that closely resemble metastatic and nonmetastatic human disease for the purposes of examining tumor biology and developing alternate treatments, human retinoblastoma cell lines were injected into the vitreal cavities of immunodeficient mice. Two reproducible animal models with contrasting biological behaviors analogous to human retinoblastoma have been developed. The Y79 retinoblastoma model demonstrated specific tumor evolution similar to that seen in human invasive and metastatic disease. Y79 retinoblastoma cells formed intraocular tumors that were initially confined to the vitreal cavity. Tumors progressively invaded the retina, subretinal space, choroid, optic nerve head, and anterior chamber of the eye. Tumors progressed into the subarachnoid space and focally invaded the brain. Metastases were detected in the contralateral optic nerve. Large tumors developed extraocular extensions. The histology of the tumors showed a poorly differentiated pattern with high mitotic rate, foci of necrosis, and calcification. The WERI-Rb model more closely resembled nonmetastatic human retinoblastoma. WERI- Rb tumors were localized in the eye with only anterior choroidal invasion at late stages. To examine potential biological differences in vitro, the retinoblastoma cell lines were cocultured with adherent choroid cells or adherent glioma cells which represent the targets of invasive retinoblastoma in vivo. Consistent with the in vivo observations, Y79 cells but not WERI-Rb cells adhere specifically to both the choroidal and the glioma cell lines.

Neonatal neoplasms

PURPOSE

To describe neoplasms diagnosed in children </= 28 days of age along with their treatment, associated congenital anomalies, and the long-term consequences of the diagnoses and treatments.

METHODS AND MATERIALS

Utilizing autopsy records, a computerized tumor registry, and medical records, we identified patients and stillborns at Duke University Medical Center (DUMC) diagnosed with neoplasms at </= 28 days of age between 1930 and 1998.

RESULTS

Twenty-three neonates with neoplasms were identified. There were 7 males (30%) and 16 females (70%). Follow-up of survivors ranged from 4 months to 27 years (mean 9 years). The 20 patients identified via the computerized registry system for 1980-1998 constitute 2% (20/925) of all neoplasms seen in patients </= 16 years of age over this same time period at DUMC. The histologic diagnoses were teratoma/germ cell tumor (n = 8, 35%), neuroblastoma (n = 5, 22%), retinoblastoma (n = 4, 17%), primary central nervous system (CNS) tumor (n = 3, 13%), and one case each of rhabdomyosarcoma, glossal glial choristoma, and hemangioma in the setting of Kasabach-Merritt Syndrome. Of the eight teratoma/germ cell tumor patients, 6 were female (75%) and 2 male (25%). There was one malignant germ cell tumor, 2 immature teratomas, and 5 teratomas. Two of the seven patients with immature teratomas or teratoma were long-term survivors following surgery. The one patient with malignant germ cell tumor, treated with surgery and chemotherapy, died. Associated anomalies were imperforate anus, congenital absence of a limb, left ventricular hypertrophy, fusion or absence of toes, coarctation of the aorta, and pulmonary valve dysplasia. Of the five children with neuroblastoma, 4 were female. INSS Stages were 1 (n = 1), 2A (n = 1), 3 (n = 1), and 4S (n = 2). Two were treated with surgery + chemotherapy + radiotherapy; two with surgery + chemotherapy; and one with surgery alone. Four children are long-term survivors. Associated congenital anomalies and medical problems were ventricular septal defect, seizure disorder, and Fanconi's anemia. A child with a dumbbell neuroblastoma, treated with surgery and chemotherapy, is paraplegic. Of the four children with retinoblastoma, two were female. Two had trilateral disease and two bilateral. Three of the four had a family history of retinoblastoma. The two children with trilateral retinoblastoma died after therapy with surgery, craniospinal and orbital irradiation, and chemotherapy. Two children with bilateral disease are long-term survivors: one treated with radiotherapy + chemotherapy and one with radiotherapy alone. They have marked orbital bone growth abnormalities. The three patients with CNS tumors were female. The histologies were glioblastoma multiforme, anaplastic astrocytoma, and malignant mixed oligodendroglioma. Two of the patients are long-term survivors after surgery + chemotherapy. Six children received eight courses of radiation therapy: 2 for Stage 4S neuroblastoma with respiratory compromise from an enlarging liver and 4 for retinoblastoma. The two infants with trilateral retinoblastoma received two courses of irradiation each: one of the treatment of intraocular tumor and a second, at an older age, for the pineal tumor. The most serious complication of anesthesia was a case of enterobacter cloacae sepsis in the central venous access line used for repetitively administering the anesthetic.

CONCLUSION

The most common neonatal neoplasm histologic diagnoses are teratoma/germ cell tumor, neuroblastoma, and retinoblastoma. Neonatal neoplasms may be associated with congenital anomalies. Radiation therapy is administered infrequently in a population highly susceptible to late ill effects. When radiotherapy is required, anesthesia may be repetitively administered to aid in reproducible treatment.