Primary Intraocular Lymphoma: A Review

Primary intraocular lymphoma (PIOL) is a type of primary central nervous system lymphoma (PCNSL). It is the most common neoplastic masquerade syndrome involving the eye. Its protean ocular manifestations, plus in many cases the initial positive response to corticosteroid therapy for presumed uveitis, delay accurate diagnosis. A high index of suspicion is essential, followed by tissue biopsy with cytology and ancillary studies. Current treatment is based on chemotherapy featuring high-dose methotrexate and radiation therapy. Prognosis is poor due to CNS involvement, but newer therapies have had some success in prolonging survival.

Evaluation of the antitumor effects of Herpes simplex virus lacking ribonucleotide reductase in a murine retinoblastoma model

PURPOSE

To determine if an attenuated herpes simplex virus (HSV) lacking the large subunit of ribonucleotide reductase has antitumor effects in a transgenic mouse model of retinoblastoma (LHbetaTAg).

METHODS

LHbetaTAg mice were injected ocularly with 1 x 10(6) pfu of the hrR3 virus and tumor sizes were measured 3 weeks later. Replication of the virus in the eye and cultured murine retinoblastoma cells was tested by titration. Distribution of the virus in tumor was measured by X-gal staining.

RESULTS

Intraocular injection of mice with hrR3 (n = 24) did not result in a significant reduction in tumor size compared to uninjected (n = 24) or PBS injected controls (n = 16). Neither the hrR3, nor the HSV RE6 mutant, which was previously shown to have antitumor effects in vivo, replicated in cultured murine tumor cells in vitro, compared to wild-type HSV. The hrR3 virus also did not replicate significantly in tumor cells in vivo, compared to normal eye tissue.

CONCLUSIONS

These results suggest that mutant HSV lacking ribonucleotide reductase do not display oncolytic activity in the LHbetaTAg mouse and that this model may not be suitable for studying viral oncolysis as a therapy for retinoblastoma.

Retinoblastoma: a three-year-study at a Brazilian medical school hospital

OBJECTIVE

To present the characteristics and treatment outcomes of patients with retinoblastoma.

METHODS

A retrospective case series was conducted to review the records of all new patients diagnosed with retinoblastoma between 2003 and 2005. Eyes with early disease, or advanced disease with potential vision were treated with chemotherapy (carboplatin and etoposide) in conjunction with early local therapy (laser or cryo). Radiotherapy was used in cases where the disease did not respond to the above protocols or in recurrent cases. Eyes in the late stage of disease with no potential vision in the initial examination or eyes and where conservative treatment had failed were enucleated.

RESULTS

In total, we reviewed 28 new cases of retinoblastoma, 15 of which were unilateral and 13 of which were bilateral (46%). These data correspond to a mean of 9.3 new cases per year (0.77 case/ month). The mean age at diagnosis was 33.8 months for unilateral cases, and 19.15 months for bilateral cases (p=0.015). Leucocoria was the major presenting symptom (75%). All but one patient with unilateral disease had the affected eye enucleated due to advanced disease (mean follow-up: 39.91 months). Among the 13 bilateral cases, 13 eyes (50%) were enucleated, 11 eyes (42.4%) were saved with chemotherapy in conjunction with local therapy and 2 eyes (7.6%) were saved using external beam radiotherapy (mean follow-up: 41.91 months). In unilateral and bilateral disease, pathology data revealed choroid involvement in 50% and 30%, respectively, and optic nerve invasion in 92% and 50%, respectively.

CONCLUSION

In this population, retinoblastoma was diagnosed too late and most eyes were consequently enucleated. In cases with bilateral disease, half of the eyes were preserved.

Chemoreduction for group E retinoblastoma: comparison of chemoreduction alone versus chemoreduction plus low-dose external radiotherapy in 76 eyes

PURPOSE

To evaluate chemoreduction (CRD) for group E retinoblastoma.

DESIGN

Retrospective, comparative case series.

PARTICIPANTS

Seventy-six eyes of 56 patients with group E retinoblastoma were treated with CRD alone or CRD plus low-dose prophylactic external beam radiotherapy (CRD+P-EBR). The CRD included vincristine, etoposide, and carboplatin (6 cycles). The P-EBR was given routinely 2 months after completion of CRD at a suggested dose of 2600 cGy. Therapeutic EBR (T-EBR) was only given at the time of extensive tumor recurrence at a suggested dose of 3800 cGy.

METHODS

Retrospective chart review.

MAIN OUTCOME MEASURES

Globe salvage.

RESULTS

Of the 76 eyes, 64 received CRD alone and 12 received CRD+P-EBR. At the 2-year follow-up, globe salvage was achieved in 29 (53%) of 55 eyes in the CRD group and in 10 (91%) of 11 eyes in the CRD+P-EBR group. At 5 years, globe salvage was achieved in 20 (48%) of 42 eyes in the CRD group and in 4 (80%) of 5 eyes in the CRD+P-EBR group (P=0.347). Of the 64 eyes in the CRD group, 16 (25%) were salvaged with CRD alone and 13 (20%) with CRD+T-EBR, whereas 22 (34%) were enucleated after CRD alone and 13 (20%) were enucleated after CRD+T-EBR. Of the 12 eyes in the CRD+P-EBR group, 10 (83%) were salvaged with CRD+P-EBR, whereas 2 (17%) were enucleated and none required T-EBR. The median dose for T-EBR was 3800 cGy, and that for P-EBR was 2600 cGy. Eyes treated with CRD+P-EBR showed significantly less recurrence, leading to less chance of enucleation or therapeutic radiotherapy than that for CRD alone (P<0.001). Visual acuity was 20/100 or better or fix and follow in 9 (32%) of 28 salvaged eyes in the CRD group and in 4 (40%) of 10 in the CRD+P-EBR group. At 5 years, there were no patients in either group with metastasis of pinealoblastoma or who had died. In one patient in the CRD group, a second cancer developed.

CONCLUSIONS

Group E retinoblastoma managed with CRD+P-EBR showed significantly less need for enucleation or therapeutic radiotherapy than eyes treated with CRD alone. These findings merit further study and consideration.

[Signs of retinoblastoma]

PURPOSE

Retrospective analysis of retinoblastoma symptoms in patients treated in Ophthalmological Clinic in Krakow.

MATERIAL AND METHODS

A retrospective chart review was conducted of 293 retinoblastoma patients from our center (1969-2008).

RESULTS

A total of 170 (58%) of 293 patients presented with leukocoria, 81 (27.6%) patients had strabismus, 22 (7.5%) had atypical sings, 12 (4.1%) was detected by chance. Eight (2.8%) patients who had a family history of retinoblastoma and were clinically screened for retinal tumors from birth were diagnosed younger.

CONCLUSIONS

We recommend routine dilated fundoscopic examination by an ophthalmologist for early detection of retinoblastoma before leukocoria and strabismus.

Retinoblastoma and deletion of the long arm of chromosome 13: an underestimated diagnosis?

We report an infant with normal neurological development and phenotype who developed bilateral retinoblastoma (RB). This patient, despite lack of dysmorphic features, demonstrated constitutional abnormality of the long arm of chromosome 13 on standard karyotype. We recommend systematic cytogenetic examinations complemented by fluorescent in situ hybridization as second-line screening in all patients suspected for hereditary RB despite negative RB1 molecular screening and normal phenotype.

[New strategies in pediatric ophthalmic oncology]

Retinoblastoma represents 11% of all cancers during the first year of life. New drugs and focal treatments have been developed in order to avoid the side effects of systemic chemotherapy and external radiotherapy. New targeted and local administration strategies such as periocular chemotherapy (topotecan) or direct ophthalmic artery delivery (carboplatin), are already used today in selected resistant cases. Radiotherapy, presently indicated only as a second-line treatment, is also subject to new techniques, targeting tumors more closely to avoid involving healthy tissue and reduce the risk of radio-induced nonocular tumors. Stereotactic conformal radiotherapy and proton therapy may thus be included in the new range of treatment methods in retinoblastoma.

Rescue of sight by gene therapy - closer than it may appear

This review will cover the state of the field in retinal degeneration and gene therapy with a focus on the great strides that have been made in retina gene therapy. Topics ranging from the development of animal models to clinical trials (for the treatment of Leber congenital amaurosis, age-related macular degeneration, and retinoblastoma) will be discussed. In addition, the results of gene therapy studies targeting the photoreceptors will be presented. Finally, strategies and progress in overcoming the challenges of photoreceptor-directed gene therapy will be presented.

Care of the child undergoing an examination under anesthesia for retinoblastoma

In conclusion, the welfare of the child is of paramount importance in the detection and treatment ofretinoblastoma. It is important for the parents to feel comfortable with the care their child is receiving since they are facing a lengthy course of therapy. Consequently, the family will require the support of the entire ambulatory surgical daycare team for years to come.

Ewing's sarcoma as second malignant neoplasm after retinoblastoma: a case report

OBJECTIVES

To report a case of a child with the hereditary form of unilateral retinoblastoma (RB), who developed Ewing's sarcoma of the right fibula 3 years after the enucleation of the right eye.

CASE PRESENTATION AND INTERVENTION

The child was diagnosed as a case of RB of the right eye at the age of 9 months. He was fully investigated and found to have locally advanced RB with bone marrow involvement (Reese-Ellsworth stage IVA). Enucleation was recommended to the family, but they refused. The patient received chemotherapy and diode laser thermotherapy in Kuwait and the UK. He had a local relapse after 11 months and subsequently underwent enucleation of the right eye. After 3 years, he was investigated for a small swelling in his right lower leg. After extensive investigations, it was reported as Ewing's sarcoma. He was treated with chemotherapy, surgery (complete excision of the fibula) and high-dose chemotherapy followed by autologous stem cell transplantation. The child is now nearly 2 years after completing the treatment and is disease free.

CONCLUSIONS

This case confirms the increased risk of a second malignant neoplasm (SMN) in children with hereditary RB. These children need a very close follow-up for the early diagnosis of SMNs or even subsequent malignancies.

Conjunctival melanoma 3 years after radiation and chemotherapy for retinoblastoma

An 8-month-old infant with advanced bilateral retinoblastoma was managed with enucleation of the right eye and chemotherapy and radiotherapy of the left eye. Three years after treatment, an ill-defined, nonpigmented mass was noted in the anophthalmic right socket. Excisional biopsy revealed an amelanotic melanoma of the conjunctiva with superficial orbital invasion. There has been no tumor recurrence during 20 months of follow-up.

[Genetics and angiogenesis: the example of von Hippel-Lindau disease]

Von Hippel-Lindau (VHL) disease is the main cause of inherited kidney cancer and the model of tumoral angiogenesis. This rare syndrome is caused by germline mutations of the VHL tumor-suppressor gene that predispose to the development of a panel of highly vascularized tumors. Main manifestations include CNS and retinal haemangioblastomas, endolymphatic sac tumors, clear-cell renal cell carcinomas (RCC), phaeochromocytomas and pancreatic neuroendocrine tumors. The VHL gene plays a major role in regulation of the oxygen-sensing pathway by targeting the hypoxia-inducible factor HIF for degradation in proteasome. Somatic inactivation of the VHL gene occurs also in most sporadic RCC. Recent progress are pawing the way for the development of antiangiogenic targeted therapies that have already shown promising results in metastatic sporadic RCC.

[Recognize the value of the individually combined therapy for children with retinoblastoma]

Retinoblastoma is the most common intraocular malignant tumor in children. With the introduction of the new therapeutic methods, the aim and the procedures of traditional therapy on retinoblastoma have been changed to the new combined therapeutic procedures, which are based on the preservation of the eyeball and visual function. Compared with the developed countries, there still exist some gaps in the acceptance of new therapeutic conceptions in China. At present, enucleation is still used commonly in China, whereas external beam radiation therapy is a main supplementary treatment. The therapeutic procedures of RB in China are relatively limited and simplistic. Therefore, the authors suggest that we should learn the experience from the developed countries, considering the status in our country, to change the traditional therapeutic idea and to establish a suitable system of individually combined therapy for patients with retinoblastoma in China.

Tumor vasoproliferativo associado à tuberculose ocular presumida: relato de caso

PURPOSE

To describe a case of vasoproliferative tumor associated with presumed ocular tuberculosis treated with cryotherapy and intravitreal triamcinolone injection.

STUDY DESIGN/PATIENT AND METHODS

Interventional case report. A 42-year-old female patient reported inflammation of the right eye 1 year ago, treated with oral prednisone for 30 days. She referred blurred vision in the right eye since childhood. Ophthalmologic examination showed 20/400 visual acuity in the right eye. Biomicroscopy and intraocular pressure were normal. Fundus examination showed vascularized elevated lesion, associated with serous retinal detachment and hard exudates at the inferior periphery. The lesion was surrounded by extensive area of hyperplastic retinal pigment epithelium. The macula showed attenuation of the foveal reflex. Ocular ultrasound showed a 2.25 mm height vascularized lesion. Serologic examination, hemogram and thorax RX were normal. PPD was considered strong reactor and tuberculosis was diagnosed after positive BK research. Considering the clinical aspects, the ocular diagnosis was vasoproliferative tumor associated with presumed ocular tuberculosis. Treatment with rifampicin, isoniazide and pyridoxine was started. We decided to treat the ocular tumor with cryotherapy and intravitreal triamcinolone injection (4 mg/ml). After 30 days, serous detachment was smaller and the tumor showed atrophic areas. Fluorescein angiography showed areas of vascular hyperfluorescence with slight extravasation and areas of blocked fluorescence due to RPE hyperplasia. Secondary vasoproliferative tumors are retinal glial proliferations and are associated with many ocular conditions that affect retina and choroid. Because of the great number of associated complications, with important visual loss, vasoproliferative tumors should be treated at the moment of diagnosis. Treatment of choice is cryotherapy. Intravitreal triamcinolone can be used as adjuvant treatment because of its angiogenic properties. Until the present moment, no ocular tuberculosis and vasoproliferative tumor association were reported in the literature. Treatment of secondary vasoproliferative tumors with cryoterapy and intravitreal triamcinolone appears as a new therapeutic choice. Further studies are necessary to prove the efficacy of this association.

Current treatment modalities for exudative retinal hamartomas secondary to tuberous sclerosis: review of the literature

BACKGROUND

Retinal hamartoma is a common finding in tuberous sclerosis, but the symptomatic changes of this lesion have rarely been described. This evidence-based review evaluated the incidence of symptomatic retinal hamartoma and compared possible treatment modalities.

METHODS

We carried out a review of the literature using MEDLINE. Older publications not listed in MEDLINE were obtained from the reference list of currently published papers.

RESULTS

Three observational case series with a follow-up of up to 34 years included 93 patients and reported progression from a flat to a more elevated lesion without visual symptoms in nine patients (9.7%). Additional symptomatic changes were described in 11 case reports published over a period of three decades. The symptomatic alterations were caused by an enlarged tumour with leakage, macular oedema, accumulating lipoid exudates, serous retinal detachment (n = 8/11) and vitreous haemorrhage (n = 4/11). Most symptomatic cases involved a retinal hamartoma type 1 (n = 6/8). Spontaneous resolution of symptomatic exudative hamartomas occurred in three patients within 4 weeks, although a delayed resorption of subretinal fluid caused permanent visual impairment in one patient. Investigational reports described a slow resorption of subretinal fluid after argon laser photocoagulation (n = 2), although recurrent laser applications induced choroidal neovascularization and destruction of the neurosensory retina (n = 1). A vitrectomy was used to remove a vitreous haemorrhage in another reported patient. In one case, complete resorption of subretinal fluid and an increase in visual acuity was observed within 2 weeks after a single treatment with photodynamic therapy (PDT). No complications were noted during a follow-up of 4 years.

CONCLUSIONS

Symptomatic changes are very rare in retinal hamartomas secondary to tuberous sclerosis. Spontaneous resolution of subretinal fluid may occur within 4 weeks. If a macular oedema with increasing lipoid exudates persists over a period of 6 weeks, treatment should be considered. Although previous reports demonstrated possible visual stabilization after argon laser photocoagulation, vision-threatening complications can occur. Current treatment strategies may include PDT based on favourable anatomical and functional results.

Vasoproliferative retinale Tumore

BACKGROUND

Vasoproliferative Tumors of the retina (VPTR) are benign tumors of unknown origin, occurring mostly in otherwise systemically healthy patients. These highly vascularised tumors are characterised by a pink to yellow colour on funduscopy and are usually situated in the inferior part of the retina. They are associated with intraretinal hemorrhages, intra- or subretinal exudates and hyperpigmentation of the retinal pigment epithelium.

MATERIALS AND METHODS

We performed a retrospective case review of seven cases which have been diagnosed with VPTR between 2004 and 2006 in the Department of Ophthalmology, University Hospital Zurich.

RESULTS

The median follow up was 8 months (range: 1-24 months). We found a presumed underlying cause for the VPTR in 6 out of 7 patients. 3 patients showed a long standing retinal detachment; in the other 3 there was an untreated chronic uveitis. In one case the tumour was surgically excised and histology was performed.

CONCLUSIONS

VPTR of the ocular fundus are a distinct entity in the differential diagnosis of intraocular tumors. These benign lesions represent reactive gliovascular proliferations, with varying degrees of both gliosis and of vascular proliferation. VPTR can be idiopathic, or they develop after inflammatory, vascular, traumatic, dystrophic or degenerative ocular diseases, in particular, uveitis. The major differential diagnosis includes other vascular lesions or tumors of the ocular fundus like capillary retinal hemangiomas, Coat' Disease or malignancies. The natural course of VPTR appears to be variable. The therapy is based on tumor size, localisation and complications.

Clinical and epidemiological characteristics of retinoblastoma: correlation with prognosis in a Turkish pediatric oncology center

Advanced intraocular tumors and metastatic disease in retinoblastoma patients still occur frequently in developing countries. The aim of this retrospective study was to describe the clinical and epidemiological characteristics of patients with retinoblastoma and the effects of these features on disease prognosis in the authors' pediatric oncology unit as a developing country profile to define the problem. A retrospective chart review of 91 patients who presented to the unit between May 1996 and December 2003 was conducted in this study. Patients with unilateral disease presented at a median age of 24 months and those with bilateral disease at a median age of 9.5 months (p < .01). Most of the eyes with retinoblastoma (68.6%) had Reese-Ellsworth stage V disease. Metastatic disease was diagnosed in 19 (20.9%) patients. Cases with metastatic disease presented at a median age of 24 months and those without metastatic disease at a median age of 12.5 months (p < .05). In 31 patients (34.1%) there was a delay in diagnosis. The enucleation ratio in eyes with advanced intraocular stage was significantly higher than in eyes with early intraocular stage (57.9 vs. 3.8%) (p < .001). In patients with metastatic disease, tumor recurrence was more frequent than in the nonmetastatic patients (36.8 vs. 4.2%) (p < .01). Seven children (7.7%) died due to central nervous system (CNS) metastasis (p < .01). Advanced intraocular disease and distant metastases occur more frequently in Turkish children with retinoblastoma than in children in developed countries, causing a higher rate of enucleation and mortality. Late referral might account for the delayed diagnosis.

Molecular pathology of eyes with von Hippel-Lindau (VHL) Disease: a review

BACKGROUND

von Hippel-Lindau Disease (VHL) is an autosomal dominant inherited systemic cancer syndrome. Recently, many advances have contributed to the understanding of VHL pathophysiology.

METHODS

In this article we review recent developments and summarize our findings in VHL molecular pathology related to retinal and optic nerve diseases.

RESULTS

Loss of heterozygosity (LOH) within the VHL gene is detected in the stromal cells surrounding the capillary endothelial cells and admixed with glial cells in ocular hemangioblastomas. This finding is in line with similar findings in VHL-associated CNS hemangioblastoma and renal clear cell carcinomas. Increases of vascular endothelial growth factor (VEGF), hypoxia induced factor (HIF), and ubiquitin are found in ocular hemangioblastomas.Interestingly, tumorlet cells, which are composed of poorly differentiated small cells with prominent dark nuclei and little cytoplasm, as well as several stem cell markers, such as erythropoietin (Epo), Epo receptor (EpoR), and CD133, are present in ocular VHL lesions. CXCR4, a CXC chemokine receptor is also expressed in retinal VHL hemangioblastomas.

CONCLUSIONS

These findings imply that VHL cells with LOH of the tumor suppressor gene, most likely originate from a hematopoietic/vascular lineage. Targeting these proteins and ischemic factors, not VEGF alone, may be a potential therapeutic approach for VHL-associated ocular hemangioblastomas.

Kapilläre Hämangiome der Netzhaut beim Von-Hippel-Lindau-Syndrom

Thermal photocoagulation of small peripheral angiomas is the treatment of choice for capillary hemangiomas in patients with von Hippel-Lindau disease. Larger peripheral angiomas are better treated with beta-ray brachytherapy resulting in improved results in terms of local tumor control and the side effects of treatment. Photodynamic treatment is an alternative option in the management of capillary hemangiomas of the retina. Further improvement of the treatment results of photodynamic therapy may be achieved by combination with intravitreal drugs. External beam radiation using either stereotactic techniques or proton radiation must be considered as experimental. The treatment of juxtapapillary angiomas is still a therapeutic dilemma. Vitreoretinal surgery should be confined to advanced stages with tractional detachment or when no other treatment option is available to salvage the eye.

Von-Hippel-Lindau-Erkrankung

Von Hippel-Lindau disease is an important hereditary tumor syndrome with a clear option for effective treatment if diagnosed in time. Interdisciplinary cooperation is the key to successful management. Major components of the disease are retinal capillary hemangioblastomas, hemangioblastomas of cerebellum, brain stem and spine, renal clear cell carcinomas, pheochromocytomas, multiple pancreatic cysts and islet cell carcinomas, tumors of the endolymphatic sac of the inner ear, and cystadenomas of the epididymis and broad ligament. A well structured screening program should be performed at yearly intervals.