[Epidemiological aspects of bilateral retinoblastoma]

Retinoblastoma (RB) is the most frequent solid tumor in the Instituto Nacional de Pediatría, México (INP). The bilateral presentation occurs in 25% of all patients. We present some epidemiological data of this form of the disease, in learn these epidemiological variables in our series. We reviewed the clinical charts from 1972 to 1994. We analyzed age, sex, timing of presentation of the second affected eye, positive family history, clinical staging, and the development of secondary malignancies. A total of 105 cases were detected from 412 RB total cases (25%). We observed a male predominance 1.6:1.0 p = 0.04 versus females. The clinical staging showed: retinal stage 9/102, ocular stage 58/102, orbital stage 26/102 and non classified 9/102 p < 0.00001. The asynchronous form is a rare presentation in our experience: 16/105 cases p = 0.00001 (15%). Only 16/105 patients had a positive family history of RB (15%). We found 2 of 105 cases with secondary malignancies (0.01%). The asynchronous form constitutes a rare presentation. We cannot explain the etiology for the high prevalence of bilateral disease. The frequency of secondary malignancies is lower than that reported in the literature.

Asynchronous bilateral retinoblastoma: the St. Jude Children's Research Hospital experience

Between May 1962 and July 1993, 172 children presented at the St. Jude Children's Research Hospital for evaluation and/or treatment of retinoblastoma (RB). Of these, 65 presented with bilateral disease, while 107 had unilateral tumors. Of these 107 patients, nine subsequently developed RB in the unaffected eye. Initial age at diagnosis of these nine patients ranged from 3 weeks to 24 months (median = 2 months); five of the nine had a family history of RB at the time of initial diagnosis and one patient, without a family history of RB, presented with unilateral multiple tumors indicating inheritance of a germinal mutation and increased risk of RB development in the companion eye. Time to development of companion eye RB was 1-61 months postinitial diagnosis. Treatment of the initial eye included enucleation (n = 4), chemotherapy (n = 3), irradiation (n = 7), or a combination of these three modalities. Reese-Ellsworth grouping of the companion eye disease included I A (n = 7), III A (n = 1), and IV A (n = 1). Treatment of the second affected eye included irradiation in seven patients, cryotherapy in four, and chemotherapy in three. No companion eye has required enucleation to date. At last followup, 14/18 eyes remain intact. There have been no cases of metastatic dissemination; however, one patient has developed a second malignant neoplasm outside the field of irradiation. Eight of the nine patients remain alive. This experience reinforces the need for close follow-up of patients diagnosed with unilateral RB, especially those with a family history of RB and those with unilateral multiple tumors.

Multinational clinical and pathologic registry of retinoblastoma. Retinoblastoma International Collaborative Study report 2

BACKGROUND

The Retinoblastoma International Collaborative Study is a multinational prospective clinical and pathologic registry designed to collect baseline clinical information, data on methods of treatment, and information on the subsequent clinical course of children with retinoblastoma.

METHODS

206 children with newly diagnosed retinoblastoma were evaluated in the participating clinical centers between 1 July 1987 and 31 December 1989. All of the children underwent comprehensive baseline assessment of multiple clinical variables prospectively according to a standard protocol. The recorded values were tabulated and analyzed.

RESULTS

The 206 children with retinoblastoma included 99 boys (48.1%) and 107 girls (51.9%). The mean age at diagnosis was 21.2 mo in the total study group. One hundred twenty-seven of the 206 children (61.7%) had unilateral disease, while 79 (38.3%) had bilateral involvement. The mean age at diagnosis in the bilateral cases (14.6 mo) was substantially less than in the unilateral ones (23.5 mo). The great majority of patients (approximately 75%) had advanced disease (group V in both Reese-Ellsworth and Essen prognosis classifications) in the affected eye (unilateral cases) or the more severely affected eye (bilateral cases).

CONCLUSIONS

This study shows that there is a dedicated group of international ophthalmologists and other physicians who are willing to participate in multicenter cooperative clinical studies of retinoblastoma and that a relatively large group of children with this ocular malignancy can be enrolled within this framework during a reasonably short time for the purposes of future studies.

[Second neoplasms after malignant diseases in childhood]

Since 1980 the German Registry of Childhood Malignancies has been established. In the framework of the long-term follow-up secondary malignancies are reported continually to the registry. An additional retrospective inquiry to all treating clinicians and principal investigators of clinical trials as well as a link to a previously existing pool of secondary malignancies (1) lead to a completion of the data. At the registry now 329 patients with second malignant neoplasms have been observed. 41.3% of them had been developed the first malignancy before the registry started its work in 1980. The most common primary malignancies are acute lymphoblastic leukaemia (ALL, 28.6%), brain tumours (12.2%), and retinoblastomas (8.8%). Compared to the population of the registry retinoblastomas as a secondary malignancy occur in excess (2.5% vs 8.8%). Most common secondary malignancies are brain tumours (20.1%), acute non-lymphoblastic leukaemia (13.1%), osteosarcomas (10.9%), and thyroid carcinomas (6.1%). Hereby especially for thyroid cancer a remarkable deviation from the frequency in the total population of the registry (0.2%) is observed. In 3% of the patients a secondary malignancy appears within a span of 10 years after the primary malignancy. This is a twentyfold increase compared with the cumulative rate of developing a malignancy in the first 10 years of life. Brain tumours after ALL (8.5%) and after other brain tumours (5.8%) and osteosarcomas after retinoblastomas (4.9%) are the most often reported combinations.(ABSTRACT TRUNCATED AT 250 WORDS)

Retinoblastoma: a model for deriving the mutation rate without using any estimate of the size of the population at risk

Paediatric cancer of the retinae arises from a transient population of stem cells whose growth and decay are responsible for the development of the fully differentiated photo-receptors and nerve cells. A model is described which fits the data on the incidence of bilateral retinoblastoma and gives the somatic mutation rate without using an estimate of the size of the population at risk. It also gives the shape of the retinoblast growth/decay curve. The model has been tested on two independent sets of data from the USA, and given that both sets are representative of the USA as a whole, there seems to have been little change in the somatic mutation rate over the last 30 or so years. For a total retinoblast formation of 4 x 10(6) cells, the average mutation rate is 2.94 x 10(-7) per cell per year.

Outcome for patients with constitutional 13q chromosomal abnormalities and retinoblastoma

The outcomes for five patients with retinoblastoma and constitutional chromosomal abnormalities involving the long arm of chromosome 13 are reported. All patients demonstrated developmental delay and mental retardation. Four of these patients are alive 23, 21, 15, and 1 year from diagnosis; one died of pneumonia with septicemia. Each of the four survivors has, with aging, shown hypotonia, mutism, contractures, and inability to function independently.

Unilateral retinoblastoma: new intraocular tumours after treatment

A retrospective chart review of 427 eyes diagnosed with unilateral retinoblastoma was performed to determine which eyes, which patients, and when new intraocular tumours would develop after treatment. Mean follow up was 8.16 years. Twenty five (6%) of 427 unilateral retinoblastoma patients developed new intraocular tumours after treatment. Five (1%) unilateral patients who were previously treated with enucleation developed new tumours (in the fellow eye). Fifteen (24%) unilateral patients who were previously treated with external beam radiation developed new tumours (equally in either eye). New tumours did not develop in the macula of either eye. The relative risk of developing new intraocular tumours after treatment was 16% in patients diagnosed before 1 year old and 2.2% for patients diagnosed after 1 year old (p < 0.001). The mean time to onset for the development of new tumours after treatment was 0.74 years; no new tumours appeared after 7.5 years of age. Those patients who are diagnosed with unilateral retinoblastoma in the first 6 months of life and have a family history of the disease are at greatest risk of developing new intraocular tumours.

Trilateral retinoblastoma--incidence and outcome: a decade of experience

PURPOSE

This report examines the incidence and outcome of trilateral retinoblastoma in children treated for retinoblastoma. A group of patients who are at highest risk for the development of trilateral retinoblastoma is defined.

METHODS AND MATERIALS

Between 1979 and 1990, 117 children were treated with external beam radiation therapy for retinoblastoma, (97/117, bilateral). Median follow-up time was 68 months. The median age at diagnosis was 7 months.

RESULTS

Six cases of trilateral retinoblastoma were identified. The incidence of trilateral retinoblastoma in children with bilateral retinoblastoma was 6% (6/97) and 10% in those with a family history of retinoblastoma. The median age at diagnosis of RB in the children with trilateral retinoblastoma, was 3 months, younger than the median age of the entire retinoblastoma group. In all cases, the pineal region was excluded from the radiotherapy fields. Treatment for the trilateral retinoblastoma consisted of craniospinal axis radiation therapy and chemotherapy in three patients, chemotherapy alone in two, and no treatment in one. All patients died from this disease. Overall, of the 117 children treated at our institution for retinoblastoma with a median follow-up of 68 months, 12 have died. Trilateral retinoblastoma was the major cause of death, accounting for 50% (6/12) of deaths.

CONCLUSION

Trilateral retinoblastoma is a major and under-appreciated cause of mortality in the first 5 years after the diagnosis of bilateral retinoblastoma. A more aggressive approach toward screening a defined population of childhood retinoblastoma survivors may be warranted.

Thirty years of retinoblastoma (1960-89): changing patterns of incidence

This study of a 30-year population-based dataset investigates further an earlier observation that the incidence of sporadic bilateral retinoblastoma appeared to be increasing in recent years in the West Midlands Health Authority Region (WMHAR). Stringent measures were applied to ensure complete ascertainment of all cases of retinoblastoma in children in the region, resulting in a total of 117 cases diagnosed during the period 1960-89 in the WMHAR. Hospital case notes were abstracted and follow-up data obtained. Incidence rates were calculated. The overall incidence remained constant over the 30-year period, but that of sporadic bilateral tumours increased, with a corresponding decline in familial cases. There was a statistically significant excess seen in Asian children.

[Malignant solid tumors in the first year of life]

The records of all children in Northern Israel under the age of 1 year in whom a malignant solid tumor was diagnosed were analyzed. Between 1973-1990 such tumors were found in 39 boys and 25 girls. The overall annual incidence was 137.1 per million, and the incidence was higher in boys (1.9/1.0), in Jews compared to non-Jews (1.3/1.0), and in Ashkenazic Jews compared to Sephardic Jews (1.2/1.0). Neuroblastoma was the most common (52% of all malignancies), followed by Wilms' tumor (13%), CNS neoplasm (11%), retinoblastoma (8%), soft tissue sarcoma (6%), lymphoma (5%) and all others (6%). The retinoblastomas were all in non-Jews, but Jews had a higher incidence of neuroblastomas. No differences in incidence were observed in other neoplasms.

[Retinoblastoma]

Retinoblastoma is the most frequent malignant tumour of the eye in the child; the median age at diagnosis is two years. A model of carcinogenesis by two successive mutations has been devised for this tumour and explains the two forms of the disease, hereditary and non-hereditary. It is most often manifested by a whitish pupillary reflection (leukocoria) or internal strabismus. Funduscopy using general anaesthesia is used to confirm diagnosis and assess endo-ocular extension. When the disease is confined to the retina, local treatment (enucleation, radiation therapy) leads to cure in a very large majority of cases. When diagnosis is made early, particularly as in familial cases, conservative treatment is possible. In intra- and extra-retinal disease, chemotherapy and radiation therapy can improve prognosis.

Retinoblastomas in Ibadan: treatment and prognosis

This study reviews the influence of different clinicopathological features of retinoblastoma on outcome and prognosis in 44 Nigerian patients. Twenty-five of the patients had a fatal outcome. These patients were younger and more frequently had bilateral retinoblastomas, orbital tumour recurrence and tumour metastases, compared to patients who had disease free survival. Postoperative tumour recurrence occurred in eleven patients and was commoner in patient who had tumour metastases. Tumour metastases occurred in eighteen of the patients. Though there has been an improvement in the prognosis of retinoblastoma at Ibadan with the advent of radiotherapy, the outlook for children with this neoplasm in this environment is still bleak in comparison with what obtains in developed countries.

[Bilateral retinoblastoma]

On the basis of analysis of the latest literature data and their own findings the authors demonstrate an increasing incidence of bilateral retinoblastomas. Clinical features of the condition are described and potentialities of its treatment discussed.

Hypofractionation in retinoblastoma: an increased risk of retinopathy

Forty-four eyes in 38 children were treated between 1963 and 1991 by external radiotherapy for retinoblastoma. Treatment modalities varied widely during this period; in addition to radiotherapy there was chemotherapy (16/44), photocoagulation (14/44), and laser therapy or cryotherapy (14/44). Treatment technique and dose fractionation also varied widely; lateral beam technique (39/44) versus anterior or anterior/lateral beam; doses per fraction ranged from 1 to 4.5 Gy, total doses from 30 to 61.5 Gy, and overall times from 22 to 49 days. Patients were followed at 3-month intervals, and actuarial survival at 10 years was 88%, with 62% local control. Ten eyes showed clinical evidence of retinopathy. A multivariate analysis of factors associated with increased risk of retinopathy was carried out using the Cox proportional hazards model and the mixture model of Farewell. The estimated latent time was 17 months (95% confidence interval, 14-20 months). The only factors found to be significantly associated with retinopathy were total dose multiplied by dose per fraction, or total dose normalized to the equivalent total dose in 2-Gy fractions as estimated from the LQ model, and these gave equivalent descriptions. There were trends (not significant) for increased risk of retinopathy when treatments included chemotherapy or photocoagulation, and for decreased risk (also not significant) when cryotherapy was used in conjunction with radiotherapy. No significance could be attached to any of the following: number of sites per eye, Reese-Ellsworth stage, and family history. We conclude that hypofractionation carries a significant risk for retinopathy in the treatment of retinoblastoma.

Exclusion from mammographic screening of women genetically predisposed to breast cancer will probably eliminate mammographically induced breast cancer

In this paper we present our view on the contribution of mammography examinations to breast cancer induction in patients with hereditary breast cancer predisposition. We contradict the usual reasoning that the benefits of early breast cancer detection outweigh the small number of induced breast cancers. Though this tenet is justified in the majority of women, yet in a small, readily identifiable group of hereditary effected women, radiation even in small doses may enhance oncogenesis. If this relatively small group of patients is barred from mammography and regularly screened with other means, mammography may even become a more safe procedure.

An increased relative frequency of retinoblastoma at a rural regional referral hospital in Miraj, Maharashtra, India

BACKGROUND

Retinoblastoma is a relatively uncommon childhood malignant neoplasm. It has been suggested previously that there is an increased incidence of retinoblastoma in India, but this has been reported primarily from urban cancer centers and may have been confounded by a referral bias.

METHODS

The authors have evaluated the relative frequency of tumors in children younger than 15 years of age from 1987 to 1990 at Wanless Hospital, a rural regional referral hospital in India.

RESULTS

Of 158 children with malignant neoplasms, 13% (20) had the histologically confirmed diagnosis of retinoblastoma. Assuming that these 158 children represent a nonbiased reflection of childhood cancer incidence in this region, these 20 cases of retinoblastoma blastoma represent a 3.3-fold increase over the expected number estimated with worldwide relative frequencies and a 4.4-fold increase over the relative frequency expected among a similar group of children as estimated with United States rates. The proportion of children with bilateral disease was 15%, which is less than expected (20-30%). The mean age at presentation was 41 +/- 14 months (mean +/- standard deviation) compared with 26 months in Western centers. In addition, 50% had metastases at the time of diagnosis compared with 5-10% at Western centers. The increased rate of metastases and late age at diagnosis suggest of a diagnostic delay.

CONCLUSIONS

These results, in combination with previously reported increased relative frequencies from urban cancer centers in India, suggest that there may be a true increase in the incidence of retinoblastoma in India. The increase in unilateral retinoblastoma indicates that environmental factors may contribute to an increase of the nonheritable form in India.

Did atomic bomb radiation influence the incidence of retinoblastoma in Nagasaki and Hiroshima?

The authors studied the effect of atomic bomb radiation in Nagasaki and Hiroshima on the incidence of retinoblastoma by examining the history of exposure to atomic bomb radiation among the grandparents and parents of retinoblastoma patients in Nagasaki and Hiroshima. Of 85 patients born in Nagasaki Prefecture from 1965 to 1986 and in Hiroshima Prefecture from 1966 to 1986, 42 had records to whether or not their grandparents and parents had been exposed to atomic bomb radiation. Seven had parents or grandparents exposed to atomic bomb radiation. These patients showed neither a high incidence of bilateral retinoblastoma nor a family history of retinoblastoma, although a higher incidence of cancer in the family history was found in the exposed group. Exposure to radiation showed no correlation with the onset of retinoblastoma. Moreover, the incidence of retinoblastoma in Nagasaki and Hiroshima Prefectures was almost the same as the average incidence in Japan. The authors failed to find evidence of increased incidence of retinoblastoma in the offspring of those exposed to atomic bomb radiation in Nagasaki and Hiroshima. However, this does not mean that the effect of radiation on the occurrence of retinoblastoma can be ruled out.

Malignant orbital tumours: observation in north Bengal

Sixty-one cases of malignant orbital tumours were analysed retrospectively in relation to the incidence, age, sex, race, anatomical site of origin of the tumours and their histological types in North Bengal. Retinoblastoma is the commonest type (65%) followed by adenocarcinoma (10%), squamous cell and basal cell carcinoma (8.8% each). Other tumours were rarely encountered.

Competing stochastic models of the incubation period: an investigation of age-at-diagnosis of familial and sporadic retinoblastoma

This study is based on the assumption that the distribution of age-at-diagnosis (a synonym for the incubation period) of a disease can convey information with respect to its pathogenetic mechanisms. To this end, an analysis of 3 retinoblastoma (RB) international data sets was undertaken. The molecular and cellular basis of RB is well understood and may serve our purpose well. RB is broken down into familial bilateral, unilateral, and sporadic unilateral forms. Survival and hazard functions were computed. Several competing stochastic models (up to 9 per RB form) were fit. Each conveyed a meaningful pathogenetic mechanism. Between-model discrimination was achieved by examining chi-square goodness-of-fit values to select the best fitting model. Well-known survival models, such as the simple exponential and the lognormal (Sartwell model) were ruled out. Age-at-diagnosis of familial RB proved to be best explained by 2 interfering exponentials (a diffonential function); the logistic was retained as the best adjusted model of the incubation period of sporadic cases of RB. As to familial unilaterals, both the diffonential and the logistic models fit equally well. The 3 data sets are consistent in these results, ruling out the less well-fit competing models. The results suggest the existence of 2 opposing but independent balancing internal mechanisms at the origin of familial RB. Sporadic RB appears to be due to a single host-dependent self-limiting cellular mechanism. Familial unilaterals which share both of these component mechanisms would involve a lower retinoblast turnover rate. The cellular implications of these findings are discussed with regard to the relative importance of endogenous and exogenous induction factors in RB. It is concluded that, according to the RB form, RB occurrence results from 2 cellular interfering forces of different strength and organization.

Retinoblastoma in the first year of life

Children diagnosed with retinoblastoma in the first year of life present with differences in laterality, stage, signs, symptoms, and respond differently to treatments when compared to older children. Of those children diagnosed in the first year of life (between 1958 and 1983 inclusive), 280 were bilateral and 121 were unilateral, the most common stage of diagnosis (for unilateral and bilateral) was Group V, and children were affected equally by sex. Children examined in the first three months of life were more often seen because of a positive family history of retinoblastoma, rather than leukocoria. Children who were treated in the first year of life frequently develop second nonocular tumors because they harbor the germinal mutation and receive radiation.

[National registry of retinoblastoma in Japan (1975-1982). The Committee for the National Registry of Retinoblastoma]

Clinical, pathological and follow-up data on 1,147 cases of retinoblastoma registered in Japan from 1975 to 1982 were statistically analysed. The cumulative survival rate of the 1,147 cases, calculated by the Kaplan-Meier method, was 93.0% at 5 years and 90.3% at 10 years. The survival rate of the 757 unilateral cases was 93.3% at 5 years and 92.3% at 10 years. For the 390 bilateral cases, however, the survival rate was 92.2% at 5 years and 86.7% at 10 years. A Cox multivariate analysis indicated that, among various clinical and pathological findings in the patients, extraocular invasion of the tumor is the most significant risk factor predictive of tumor death. The survival rate of those with extraocular invasion subsequently treated by local radiation and/or systemic chemotherapy was significantly better than the rate of those with extraocular invasion who did not receive aftercare. The cumulative incidence rate of second cancers in 409 cases of hereditary retinoblastoma was 4.8% at 10 years, 9.8% at 15 years and 15.7% at 20 years. The occurrence of a second cancer was the main cause of death in the hereditary cases after 10 years.

The aetiology of cancer in the very young

Epidemiological studies of cancer in young children have implicated a number of environmental factors, which need to be studied in more detail, but it is probably fair to say that the main benefit of these studies has come from the negative findings, which have served to exclude (or at least place an upper limit on the role of) potential risk factors. Our inability to identify environmental causes could mean either that the environment does not substantially affect cancer incidence in young children, or that we are simply not looking in the right places. Most attention has naturally been focused on the known and suspected environmental carcinogens and mutagens. Based on the data summarised in this paper, one possibility is that the most important mutagen is endogenous: 5-methyl-cytosine. If so, factors increasing cancer risk could be those which increase the rate of spontaneous deamination, or impair the efficiency of the excision repair enzymes, or regulate the processes of CpG methylation and demethylation. These factors could still be classed as mutagens in their own right, since they would lead to an increase in uncorrected point mutations, but they would be distinctive in a number of ways. Firstly, since the role of methylation in bacteria is very different from that in eukaryotic cells the Ames mutagenicity assay could not be relied upon to detect methylation-mediated mutagens. Furthermore the risk may be highly age dependent, reflecting changes in methylation patterns with growth and cellular differentiation. Agents which disrupted the imprinting process in the testis would not be detectable by animal carcinogenicity tests unless specifically looked for.(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns of risk of hereditary retinoblastoma and applications to genetic counselling

A registry including information about nearly 1,600 cases of retinoblastoma diagnosed in Britain has been created at the Childhood Cancer Research Group. Cases have been classified as 'old germ cell mutation', 'new germ cell mutation' or 'sporadic non-hereditary'. For a population-based group of 918 cases diagnosed between 1962 and 1985 we have calculated the proportions of unilateral/bilateral and hereditary/non-hereditary cases. Bilateral cases represent 40% of the total number over this period; the proportion known to be hereditary is 44%, a higher proportion than has been reported elsewhere. By following up selected groups of cases, an estimate has been made of the proportions of siblings of retinoblastoma patients and offspring of survivors from retinoblastoma who are themselves affected with the disease. Where there is no previous family history, the risk for siblings of retinoblastoma patients of developing the disease is approximately 2% if the disease in the affected child is bilateral and 1% if it is unilateral, assuming that there are no other siblings; if there are unaffected siblings the risks for subsequent children are lower. Children of patients with hereditary retinoblastoma have a one in two chance of carrying the germ cell mutation and for those who are carriers the probability of developing retinoblastoma is very close to the accepted figure of 90% if the parents have bilateral retinoblastoma but probably less if they have the unilateral form. For children of patients not known to be carriers, the probability of developing retinoblastoma is estimated to be about 1%, considerably lower than the previously accepted figure of about 5%. Retinoblastoma kindreds consist mainly of bilateral cases but there is evidence that some kindreds have a high proportion of unilateral cases. The ways in which these findings may be used in conjunction with modern techniques of molecular biology for prenatal and postnatal genetic counselling are discussed.

[Analysis of 26,826 patients with tumors in the head and neck]

A series of 26,826 patients with tumors in the head and neck as confirmed by pathology from January 1970 to December 1989 are analyzed. It accounted for 39.5% of all the tumors biopsied in the same interval. In this series, 72.41% was malignant which accounted for 45.77% of malignant tumors in the whole body. For benign tumors in the head and neck, the ratio of male to female was 0.84:1, and for malignant tumors in the head and neck it was 2.4:1. The most frequently involved site by the malignant tumors were: nasopharynx, mouth, maxillofacial regions and neck. The majority (62.65%) of malignant tumors were located in the nasopharynx which accounted for 28.68% of all malignancies, of which the ratio of male and female was 3:1, peak age was 41-50 years, 18 of them was under 10 years of age, the youngest was 1 1/2 years and the oldest was 84 years old. These data showed that malignant tumors in the head and neck regions, especially those in the nasopharynx, are common in Guangxi Province, China.

[Radiation management of retinoblastoma]

Forty-five patients with retinoblastoma were treated at Keio University Hospital from 1970 to 1990. Thirty-two patients had unilateral lesions and 13 had bilateral lesions. Twenty-nine patients with unilateral and 12 with bilateral lesions underwent enucleation for advanced tumor. As a result, 3 patients with unilateral retinoblastoma and all patients with bilateral disease were treated with radiotherapy (40-50 Gy) combined with or without cryotherapy and/or photocoagulation. One patient with unilateral lesion treated with radiotherapy and chemotherapy had metastases at the first visit to our clinic and was excluded from this analysis. Among 16 eyes (15 patients) treated with radiotherapy, 6 eyes had recurrence and needed retreatment. Cataract occurred in 6 of 12 eyes and good vision was preserved in 5 of 10 eyes in which function could be evaluated.

Childhood cancer in the West Midlands: incidence and survival, 1980-1984, in a multi-ethnic population

The purpose of this study is to describe the incidence and survival of childhood cancer in the West Midlands for the period 1980-1984. Proportional breakdown by Asian subgroup is also considered. A total of 587 patients were registered, 49 of them of Asian origin. Breakdown to Asian versus non-Asian subgroups by diagnosis revealed comparatively high rates for Hodgkin's disease, retinoblastoma and neuroblastoma in the Asian patients. However, a deficit of cases was seen for CNS tumours. Comparison of overall age-standardized rates (ASR) for all cancers revealed a substantially lower value compared to that reported for the USA white population but a similar value to the USA black and UK white populations. Diagnostic breakdown revealed that the major difference between the West Midlands Regional Children's Tumour Research Group (WMRCTRG) and the USA white ASR was in the leukaemia and lymphoma group. Overall survival for the series was 56% at 5 years. The poorest prognosis was found in acute myeloid leukaemia, with only 23% of patients surviving at 5 years, against 62% in acute lymphoblastic leukaemia. CNS tumours also had a poor outcome, with an overall survival rate of 47%, although certain individual diagnoses were more favourable. We observed a 100% survival rate in Hodgkin's disease up to 5 years from diagnosis, and both Wilms' tumour and retinoblastoma had 90% survival rates.

Cumulative incidence of retinoblastoma in Riyadh, Saudi Arabia

A survey of all hospitals in the city of Riyadh for retinoblastoma cases presenting during the period 1982-1986 was performed; 22 cases (16 females and six males) were identified. The cumulative live births in the city of Riyadh for the same period numbered 254,780. The authors report the cumulative incidence of retinoblastomas in Riyadh, Saudi Arabia as 1:11580 live births per year.

Advances in management of retinoblastoma

Retinoblastoma is a highly malignant intraocular tumor of children that requires accurate diagnosis to prompt treatment. This article reviewed clinical, pathological and follow-up data on 1 147 cases of retinoblastoma registered in Japan from 1975 to 1982. It is obvious that the prognosis of children with retinoblastoma has improved remarkably in recent years. The current advances in the management of the retinoblastoma were discussed.

[Clinico-statistical observations on malignant ocular tumors surgically resolved at the Cluj-Napoca Ophthalmological Clinic between 1970 and 1990]

During the period mentioned above there ware hospitalized 54 patients having epibulbar tumours. The anatomopathological exam which was effectuated for 33 patients hes shown Bowen's disease for 14 cases, spinocellular carcinoma for 15 patients and basocellular for 3 patients. There were 4 cases for epibulbar precancerous. There was retinoblastoma for 19 cases; it had been practiced the enucleation of ocular globe for 17 patients and for two cases it had been practiced the exenteration of the eye socket. At the same period there were 91 uveal melanosis 6 of which having iridial localization, 10 cases of ciliary body [correction of cylar corpus], 75 cases of choroid. The hepatic scintigraphy was practiced for 56 patients and had shown for 8 cases hepatic metastasis. The histopathological exam of the melanomata of ciliary and choroidal corpus had shown type A fusiform cells for 22 cases, type B for 43 cases, epithelioid cells for 6 cases and mixed type cells for 13 cases. The hepatic metastasis were epithelioid cells for all the cases and, for 2 cases there were with mixed type cells, It is necessary an active discovering of intraocular and episcleral malign tumours, for increasing the chance of an earlier diagnosis during a stadium that would be able to be treated as conservator as possible be.

[Neoplasms during the 1st year of life: a study of 116 cases treated during the last 10 years]

116 infants under one year of age (14 per 100) with malignancies including 35 neuroblastomas, 23 retinoblastomas, 14 Wilm's tumours, 10 hepatoblastomas, 10 brain tumours, 9 germ cell tumours, 8 histiocytic and 7 soft tissue sarcomas, were treated in the last ten years. Hepatoblastoma is the highest relative incidence tumor in the first year of life and with brain tumours has the worst prognosis (50 and 40 per 100, respectively). The disease-free survival rate is most than 80 per 100 in neuro and nephroblastoma with medical and surgical treatment. Familiar incidence in Wilm's tumor is 42 per 100 and chemotherapy side effects are 23 per 100. Familiar incidence in neuroblastoma is 20 per 100 and chemotherapy side effects 21 per 100. In conclusion, in children with malignancies under one year of age have good prognosis (75 per 100 survival at five years), with lower surgical complications rate. Early diagnosis and response to chemotherapy, the side effects of which are considerable and should be strictly controlled, are key factors in the better prognosis and increased life expectancy in this group of patients.

Survival rate and risk factors for patients with retinoblastoma in Japan. The Committee for the National Registry of Retinoblastoma

Clinical, pathological and follow-up data on the 1,147 cases of retinoblastoma registered in Japan from 1975 to 1982 were statistically analyzed. The cumulative survival rate of the total 1,147 cases was 93.0% at 5 years and 90.3% at 10 years, calculated by the Kaplan-Meier method. The survival rate for the 757 unilateral cases was 93.3% at 5 years and 92.3% at 10 years. For the 390 bilateral cases, however, the rate was 92.2% at 5 years and 86.7% at 10 years. The Cox multivariate analysis indicated that, among the various clinical and pathological findings in the patients, extraocular invasion by the tumor was the most significant risk factor which is predictive of death due to tumor. The survival rate for patients with extraocular invasion was significantly better in cases undergoing subsequent local radiation and/or systemic chemotherapy than in cases without such aftercare. The cumulative incidence rate of second neoplasms in 409 cases of hereditary retinoblastoma was 4.8% at 10 years, 9.8% at 15 years and 15.7% at 20 years. The occurrence of a second neoplasm was the main cause of death in the hereditary cases 10 years after the first onset.

Incidence of retinoblastoma in Nagasaki Prefecture, Japan

From 1965 to 1986, thirty-four patients with retinoblastoma were born in Nagasaki Prefecture, Japan, 23 with unilateral and 11 with bilateral retinoblastoma. The incidence of retinoblastoma was calculated to be approximately 1 in 16,053 births; it was bilateral in 1 in 49,618 births. There was no significant difference in the incidence of retinoblastoma between urban and rural areas. In Shimabara district it was 1 in 10,331 births--much higher than in any other district of Nagasaki Prefecture. Historically, almost all the natives had been killed in the Shimabara War in 1637, and then people immigrated to Shimabara mainly from Hyogo, Aichi and Shizuoka Prefectures. The authors compared the incidence and distribution of retinoblastoma in these three prefectures with the figures in Shimabara. The incidence in the Tamba and Tajima districts of Hyogo Prefecture was 1 in 10,570 and 1 in 10,411, respectively, very similar to that in Shimabara. The authors wonder if this similarity is only an accidental coincidence when the historical relationship among the three districts is considered.

Cobalt60 plaques in recurrent retinoblastoma

Cobalt60 plaque irradiation is one treatment option for patients with recurrent retinoblastoma following conventional external beam irradiation (ERT). Tumorocidal doses can be delivered without excessive risk of normal tissue injury. In patients not considered candidates for xenon arc or cryotherapy, 60Co is an alternative to enucleation. Between 1968 and 1987, 85 patients were treated with 60Co plaques, 72 of whom had failed prior ERT. Age at diagnosis ranged from 1 week to 4 years. There are 37 males and 35 females. Seventy-one patients had bilateral disease and one had unilateral. Three patients had both eyes plaqued. Prior ERT ranged from 30 to 70 Gy (mean 4200 Gy). Time from initial therapy to failure ranged from 13 to 60 months. Cobalt plaques of 10 mm, 15 mm, or 10 x 15 mm were used depending on tumor size and location. Dose prescribed to the apex of the tumor ranged from 30 to 50 Gy (median 40 Gy) given over 3 to 8 days. Twelve patients had two plaque applications; three patients had three plaque applications. All patients were followed with routine ophthalmoscopic examinations. Follow-up ranged from 2 to 22 years (mean 8.7). Seven patients died of metastatic disease; 10 patients developed non-ocular second tumors. Thirty patients required enucleation. Twenty-two patients had clear tumor progression, two patients had radiation complications, and six patients had a combination of tumor growth and complications. Cobalt60 can salvage eyes in retinoblastoma patients failing ERT. Currently, we are using I125 in an attempt to spare normal ocular tissue and reduce subsequent complications.

Italian register for retinoblastoma. Pros and cons of a retrospective statistical study

In an attempt to verify some of the current conflicting results concerning the impact of relevant prognostic factors in the retinoblastoma therapy, the authors took into consideration, for statistical analysis, the series of 459 cases included in the Italian Registry for retrospective study of retinoblastoma. Although this series appears large enough, problems related to the continuously changing approaches to the disease and the consequent lack of standardization often make it difficult to draw significant conclusions. Hence, while historical (retrospective) analysis often allows the manipulation of a great number of data, particularly in the case of relatively rare diseases, prospective randomized controlled trials are strongly recommended to standardize definitely the relevant prognostic criteria. These and other problems related to retrospective analysis are discussed in detail.

Childhood retinoblastoma

Childhood retinoblastoma was studied in a period of January 1980 to December 1988. Forty six patients were included consisting of 21 males (45.65%) and 25 females (54.35%). Most of those patients (76.08%) were in the age group of 0-5 years. The main complaint was protrusion of eyes, found in 42 patients (91.30%). Bone marrow examination was done in 24 patients, and 52.17% of them showed sign of metastasis. Thirty seven cases had unilateral retinoblastoma (80.43%). The statistical analysis indicated no significant differences in sex and age, site of tumor (left or right eye), abnormality of the eyes, bone marrow involvement, protrusion of the eyes either unilateral or bilateral. Heredity was found in one patient (2.17%). The main treatment was radiation in 25 patients (50.43%).

[A numerical overview of various forms of retinoblastoma]

The retinoblastoma is the most frequent intraocular tumour in early childhood occurring in a hereditary as well as non-hereditary form and showing an increasing incidence since the beginning of this century, which has nowadays stabilized near 1/16,000. Further differentiation is necessary in view of unilateral and bilateral as well as sporadic and familiar occurrence. Estimates of the relative frequencies of the resulting different groups are given und summarized in two tables in two different aspects.

[Genetics and genetic counseling: the retinoblastoma case]

Forty-percent of retinoblastomas are due to a mutation inherited as an autosomal dominant trait with a high penetrance. Cytogenetic forms of retinoblastoma have led to the location of the gene, to the identification of numerous chromosome 13 specific DNA polymorphisms, and to the cloning of the gene. Intragenic DNA polymorphisms are now known. Using Southern blot hybridization, study of the mutation is possible either by direct analysis or by an indirect approach using linkage with polymorphic genetic markers. The majority of cases cannot be examined by these techniques. Their value and limits are discussed.

Parental age in sporadic hereditary retinoblastoma

Of 104 children with sporadic hereditary retinoblastoma born between 1945 and 1970, we studied the age of their parents at the birth and compared this age with the mean age of parents at the birth of their children during the same period in The Netherlands. The mean age of fathers at the birth of their children with sporadic hereditary retinoblastoma (33.7 years) was significantly higher than the mean age of fathers at the birth of their children in the general population (32.5 years) (P less than .05, one sided). Similarly, the mean age of mothers at the birth of their children with sporadic hereditary retinoblastoma (31.2 years) was significantly higher than the mean age of mothers at the birth of their children in the general population (29.5 years) (P less than .05, one sided). We further analyzed this parental age factor by measuring the relative risk of age groups and comparing the incidence of sporadic hereditary retinoblastoma in the various parental age groups with the incidence of sporadic hereditary retinoblastoma in the total population. Mothers 35 years of age or older had a relative risk of 1.7 to have a child with sporadic hereditary retinoblastoma compared with mothers in the population in general (P = .006, one sided). Similarly, fathers 50 years of age or older had a relative risk of 5.0 to have a child with sporadic hereditary retinoblastoma compared with fathers in the population in general (P = .04, one sided). No parental age effect was found in children with nonhereditary retinoblastoma. We conclude that a high paternal and a high maternal age are significant risk factors for sporadic hereditary retinoblastoma.

Molecular genetics in the pathology and diagnosis of retinoblastoma

Retinoblastoma, the most common intraocular malignancy of children, has served as an important paradigm for understanding the events involved in neoplastic transformation. Much of the contemporary molecular description of human cancers stems directly from experimental approaches first developed to study this childhood tumour. This analytical methodology has demonstrated a major role for heritable predisposition in tumourigenesis, provided evidence for tissue pleiotropy of cancer genes, and revealed a more precise estimation of the number, activity, and location of other tumour suppressor loci.

The epidemiology of ophthalmic malignancies in New York State

The epidemiologic characteristics of more than 1400 primary eye cancers (ICD-9, site 190) diagnosed among New York State (NYS) residents between 1975 and 1986 are described. Among NYS male residents, the average annual age-adjusted incidence rate was 7.5 per 1,000,000, and among NYS female residents, the rate was 5.4 per 1,000,000 (male:female rate ratio, 1.39). The majority of ophthalmic malignancies were included within three histologic groupings: melanomas (70.4%), retinoblastomas (9.8%), and squamous cell carcinomas (9.2%). The average annual incidence of retinoblastoma among persons in NYS who were less than 5 years of age was 9.5 per 1,000,000 for boys and 8.7 per 1,000,000 for girls (male:female rate ratio, 1.09). The average annual incidence (age-adjusted) of ocular melanomas was 4.9 per 1,000,000 among men and 3.7 per 1,000,000 among women in NYS (male:female rate ratio, 1.32). Expanded knowledge of the epidemiology of ophthalmic cancers can help to develop a foundation on which to monitor disease patterns and can serve to stimulate further etiologic research involving these rare malignancies.

Increasing incidence of retinoblastoma?

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Malignant tumors during the first 2 decades of life in the offspring of atomic bomb survivors

The risk of cancer (incidence) prior to age 20 years has been determined for children born to atomic bomb survivors and to a suitable comparison group. Tumor ascertainment was through death certificates and the tumor registries maintained in Hiroshima and Nagasaki. The rationale for the study stemmed from the evidence that a significant proportion of such childhood tumors as retinoblastoma and Wilms tumor arise on the basis of a mutant gene inherited from one parent plus a second somatic cell mutation involving the allele of this gene. Gonadal radiation doses were calculated by the recently established DS86 system, supplemented by an ad hoc system for those children for one or both of whose parents a DS86 dose could not be computed but for whom an ad hoc dose could be developed on the basis of the available information. The total data set consisted of (1) a cohort of 31,150 live-born children one or both of whose parents received greater than 0.01 Sv of radiation at the time of the atomic bombings (average conjoint gonad exposure 0.43 Sv) and (2) two suitable comparison groups totaling 41,066 children. Altogether, 43 malignant tumors were ascertained in the children of exposed parents, and 49 malignant tumors were ascertained in the two control groups. A multiple linear regression analysis revealed no increase in malignancy in the children of exposed parents. However, examination of the data suggested that only 3.0-5.0% of the tumors of childhood that were observed in the comparison groups are associated with an inherited genetic predisposition that would be expected to exhibit an altered frequency if the parental mutation rate were increased. There is thus far no confirmation of the positive findings that Nomura found in a mouse system.