Retinoblastoma seeds: impact on American Joint Committee on Cancer clinical staging

AIM

To investigate whether the American Joint Committee on Cancer (AJCC) clinical category cT2b needs to be subclassified by the type and distribution of retinoblastoma (RB) seeding.

METHODS

Multicentre, international registry-based data were collected from RB centres enrolled between January 2001 and December 2013. 1054 RB eyes with vitreous or subretinal seeds from 18 ophthalmic oncology centres, in 13 countries within six continents were analysed. Local treatment failure was defined as the use of secondary enucleation or external beam radiation therapy (EBRT) and was estimated with the Kaplan-Meier method.

RESULTS

Clinical category cT2b included 1054 eyes. Median age at presentation was 16.0 months. Of these, 428 (40.6%) eyes were salvaged, and 430 (40.8%) were treated with primary and 196 (18.6%) with secondary enucleation. Of the 592 eyes that had complete data for globe salvage analysis, the distribution of seeds was focal in 143 (24.2%) and diffuse in 449 (75.8%). The 5-year Kaplan-Meier cumulative globe-salvage (without EBRT) was 78% and 49% for eyes with focal and diffuse RB seeding, respectively. Cox proportional hazards regression analysis confirmed a higher local treatment failure risk with diffuse seeds as compared with focal seeds (hazard rate: 2.8; p<0.001). There was insufficient evidence to prove or disprove an association between vitreous seed type and local treatment failure risk(p=0.06).

CONCLUSION

This international, multicentre, registry-based analysis of RB eyes affirmed that eyes with diffuse intraocular distribution of RB seeds at diagnosis had a higher risk of local treatment failure when compared with focal seeds. Subclassification of AJCC RB category cT2b into focal vs diffuse seeds will improve prognostication for eye salvage.

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

PURPOSE

To evaluate presenting features, tumor size, and treatment methods for risk of metastatic death due to advanced intraocular retinoblastoma (RB).

DESIGN

International, multicenter, registry-based retrospective case series.

PARTICIPANTS

A total of 1841 patients with advanced RB.

METHODS

Advanced RB was defined by 8th edition American Joint Committee on Cancer (AJCC) categories cT2 and cT3 and new AJCC-Ophthalmic Oncology Task Force (OOTF) Size Groups (1: < 50% of globe volume, 2: > 50% but < 2/3, 3: > 2/3, and 4: diffuse infiltrating RB). Treatments were primary enucleation, systemic chemotherapy with secondary enucleation, and systemic chemotherapy with eye salvage.

MAIN OUTCOME MEASURES

Metastatic death.

RESULTS

The 5-year Kaplan-Meier cumulative survival estimates by patient-level AJCC clinical subcategories were 98% for cT2a, 96% for cT2b, 88% for cT3a, 95% for cT3b, 92% for cT3c, 84% for cT3d, and 75% for cT3e RB. Survival estimates by treatment modality were 96% for primary enucleation, 89% for systemic chemotherapy and secondary enucleation, and 90% for systemic chemotherapy with eye salvage. Risk of metastatic mortality increased with increasing cT subcategory (P < 0.001). Cox proportional hazards regression analysis confirmed a higher risk of metastatic mortality in categories cT3c (glaucoma, hazard ratio [HR], 4.9; P = 0.011), cT3d (intraocular hemorrhage, HR, 14.0; P < 0.001), and cT3e (orbital cellulitis, HR, 19.6; P < 0.001) than in category cT2a and with systemic chemotherapy with secondary enucleation (HR, 3.3; P < 0.001) and eye salvage (HR, 4.9; P < 0.001) than with primary enucleation. The 5-year Kaplan-Meier cumulative survival estimates by AJCC-OOTF Size Groups 1 to 4 were 99%, 96%, 94%, and 83%, respectively. Mortality from metastatic RB increased with increasing Size Group (P < 0.001). Cox proportional hazards regression analysis revealed that patients with Size Group 3 (HR, 10.0; P = 0.002) and 4 (HR, 41.1; P < 0.001) had a greater risk of metastatic mortality than Size Group 1.

CONCLUSIONS

The AJCC-RB cT2 and cT3 subcategories and size-based AJCC-OOTF Groups 3 (> 2/3 globe volume) and 4 (diffuse infiltrating RB) provided a robust stratification of clinical risk for metastatic death in advanced intraocular RB. Primary enucleation offered the highest survival rates for patients with advanced intraocular RB.

High-risk Pathologic Features Based on Presenting Findings in Advanced Intraocular Retinoblastoma: A Multicenter, International Data-Sharing American Joint Committee on Cancer Study

PURPOSE

To determine the value of clinical features for advanced intraocular retinoblastoma as defined by the eighth edition of the American Joint Committee on Cancer (AJCC) cT3 category and AJCC Ophthalmic Oncology Task Force (OOTF) Size Groups to predict the high-risk pathologic features.

DESIGN

International, multicenter, registry-based retrospective case series.

PARTICIPANTS

Eighteen ophthalmic oncology centers from 13 countries over 6 continents shared evaluations of 942 eyes enucleated as primary treatment for AJCC cT3 and, for comparison, cT2 retinoblastoma.

METHODS

International, multicenter, registry-based data were pooled from patients enrolled between 2001 and 2013. High-risk pathologic features were defined as AJCC categories pT3 and pT4. In addition, AJCC OOTF Size Groups were defined as follows: (1) less than half, (2) more than half but less than two thirds, (3) more than two thirds of globe volume involved, and (4) diffuse infiltrating retinoblastoma.

MAIN OUTCOME MEASURES

Statistical risk of high-risk pathologic features corresponding to AJCC cT3 subcategories and AJCC OOTF Size Groups.

RESULTS

Of 942 retinoblastoma eyes treated by primary enucleation, 282 (30%) showed high-risk pathologic features. Both cT subcategories and AJCC OOTF Size Groups (P < 0.001 for both) were associated with high-risk pathologic features. On logistic regression analysis, cT3c (iris neovascularization with glaucoma), cT3d (intraocular hemorrhage), and cT3e (aseptic orbital cellulitis) were predictive factors for high-risk pathologic features when compared with cT2a with an odds ratio of 2.3 (P = 0.002), 2.5 (P = 0.002), and 3.3 (P = 0.019), respectively. Size Group 3 (more than two-thirds globe volume) and 4 (diffuse infiltrative retinoblastoma) were the best predictive factors with an odds ratio of 3.3 and 4.1 (P < 0.001 for both), respectively, for high-risk pathologic features when compared with Size Groups 1 (i.e., < 50% of globe volume).

CONCLUSIONS

The AJCC retinoblastoma staging clinical cT3c-e subcategories (glaucoma, intraocular hemorrhage, and aseptic orbital cellulitis, respectively) as well as the AJCC OOTF Size Groups 3 (tumor more than two thirds of globe volume) and 4 (diffuse infiltrative retinoblastoma) both allowed stratification of clinical risk factors that can be used to predict the presence of high-risk pathologic features and thus facilitate treatment decisions.

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.

Evaluation of an automatic hematology analyzer in patients with nonhematologic conditions

The Coulter STKS is a new automated hematology analyzer that provides complete blood counts (CBCs) and a five-part white blood cell (WBC) differential count. This study evaluated its performance and determined its value in reducing the extensive manual work required to obtain WBC differential counts from patients with nonhematologic conditions. The evaluations included precision, carryover, effects of storage duration and temperature, comparison of primary (automated) and secondary (manual) methods of aspiration, comparison with the Technicon H*1 machine, and WBC differential capability. Both primary and secondary methods provided CBC values that were precise, repeatable, and satisfactory. The WBC differential results also were accurate and comparable to those obtained manually. The Coulter STKS not only precisely analyzes CBCs but also screens blood samples without WBC abnormalities, as it has a 98% predictive value of negative test results. This instrument is suitable for use in nonhematology patients in large medical centers, teaching hospitals, and general hospitals.

HLA antibodies in multiple transfused patients

Totally 86 patients with multiple transfusions were followed up regularly for more than six months. Their sera were screened for HLA antibodies every two to four weeks. Subsequently 28 (33%) of them developed HLA antibodies. The specificities of identified antibodies were anti-A2, All, B16 and B60. However, most of the antibodies were either multiple or undetermined. The panel reactive activity (PRA) was correlated with the amount of blood components transfused. We concluded that about one third of the patients will develop HLA antibodies after multiple transfusions and the reactivity of the antibodies is correlated to the amount of blood components transfused.

Detection of antibodies to human immunodeficiency virus (HIV-1) with the particle agglutination test

This study was designed to evaluate the sensitivity and specificity of the particle agglutination test (PA) for antibody detection and to determine whether it is possible to use this test as a screening routine for anti-human immunodeficiency virus type I antibodies instead of the enzyme linked immunosorbent assay (ELISA). Serum samples were collected from 5,142 subjects and tested with the above two tests. A total of 83 samples were observed to be ELISA-positive. However, only 36 were found to be seropositive by the PA test. These samples were then confirmed by the Western blot analysis and 28 were positive for HIV-1, 33 were negative and 22 gave indeterminate results. The most common indeterminate band was p15/17 and the p24 band came next. The sensitivity and specificity of the PA test were 100% and 99.9%. The results indicate that the PA test is not only a convenient technique but also has a high sensitivity and specificity. It can be used as a primary screening test for antibody against HIV-1 instead of the ELISA.

Evaluation of carcinoembryonic antigen, tissue polypeptide antigen, and squamous cell carcinoma antigen in the detection of cervical cancers

Cervical cancer is a predomiannt gynecologic neoplasia in Taiwan. The associations of carcinoembryonic antigen (CEA), tissue polypeptide antigen (TPA) and squamous cell carcinoma antigen (SCC-Ag) for detection of cervical cancers with type of cancer, clinical stage and lymph node metastasis were studied. Serum samples were collected from 395 patients with cervical cancers (61 CIN3, 334 squamous cell carcinoma, 18 adenocarcinoma), 72 patients with benign gynecologic diseases and 115 healthy controls. The sensitivities of CEA, TPA, and SCC-Ag were 15.2%, 33.6%, and 49.3%. The specificities were 89.3%, 96.2%, and 95.1%, respectively. The positive rate of CEA was found significantly higher among patients with adenocarcinoma than those with squamous cell carcinoma. The positive rate of CEA and SCC-Ag increased with advance of the clinical stages. There was no significant difference in the rate of each tumor marker between patients with lymph node metastasis and those without metastasis. The positive rate obtained by SCC-Ag alone was comparable to those by the combinations of two or three antigens. The result of the present study indicates that SCC-Ag is the most useful tumor marker in the detection of cervical cancers.

Evaluation of the effectiveness of different brands' disks in antimicrobial disk susceptibility tests

A total of 813 routine isolates of aerobic and facultatively anaerobic bacteria were employed to determine the efficacy of different branded (Oxoid, Difco, BBL) antimicrobial disks, using disk antimicrobial susceptibility tests, for a total of 22 kinds of antimicrobial disks and 10,740 antibiotic-organism comparisons. Major positive and major negative discrepancies in results were defined as a change from "susceptible" to "both resistant", and a change from "resistant" to "both susceptible" according to the National Committee for Clinical Laboratory Standards' interpretive standards for zone diameters. Minor positive and minor negative discrepancies were defined as a change from "susceptible" to "both intermediate", or "intermediate" to "both resistant"; and a change from "resistant" to "both intermediate", or "intermediate" to "both susceptible". The overall agreements of Oxoid, Difco, and BBL systems were 98%, 98.7%, and 98.4% respectively, and their differences are not statistically significant. Different kinds of antimicrobial disks' representative patterns of these three brands are further analyzed: (A) In the Oxoid series, there were 220 discrepancies. Minor negative discrepancy is predominant, most frequently related to carbenicillin (25), gentamicin (13) and cephalothin (10). Besides minor negative discrepancy, carbenicillin also had six minor positive discrepancies. Tetracyclin had ten minor positive discrepancies. (B) In the Difco series, there were 137 discrepancies. The majority of them are minor positive discrepancies. Moxalactam (11) and cefotaxime (10) are the most common antibiotics involved. (C) In the BBL series, there were 170 discrepancies. Minor positive discrepancy was the predominant one, which mostly related to carbenicillin (24), amikacin (13), and ceftizoxime (12). In addition, tetracyclin had 24 times minor negative discrepancies. Laboratory workers must pay attention to these different patterns of representation. In order to evaluate the quality of 11 pairs of the give-away and the purchased BBL disks, we also compared the results for these 813 routine isolates (a total of 5,482 antibiotic-organism comparisons). The giveaway disks demonstrated 99.1% overall agreement with the purchased disks. There were 48 minor discrepancies [26 (0.47%) minor positive discrepancies and 22 (0.4%) minor negative discrepancies]. These results allow this study to emphasize the followings in order to raise the awareness of the laboratory workers: (i) alteration of disk efficacy during transportation and storage; (ii) major considerations in choosing different brands' antimicrobial disks, and (iii) the important roles played by salespersons and pharmaceutical companies in achieving sound results.