Outcomes in retinoblastoma, 1974?2005: The Children's Hospital, Westmead

BACKGROUND

To report the 31-year experience of outcomes in retinoblastoma from a single centre.

METHODS

A retrospective analysis of consecutive cases of retinoblastoma diagnosed and treated at the Westmead Children's Hospital, Sydney between 1974 and 2005 was performed. The subjects were analysed as two groups: those diagnosed between 1974 and 1989 (series alpha) and those diagnosed between 1990 and 2005 (series beta).

RESULTS

There were a total of 142 patients included in the study, with a median follow up of 72 months. There were 84 patients with unilateral disease and 58 patients (116 eyes) with bilateral disease. The total enucleation rate remained high throughout both series for those with unilateral disease: 89% (series alpha) and 95% (series beta). There was a reduction in enucleations performed for those with bilateral disease from 68.4% (series alpha) to 43.6% (series beta) (P < 0.025). There were no bilateral enucleations performed after 1995. Actuarial Kaplan-Meier curves showed that 56% of all preserved eyes had not recurred at a median follow up of 95 months and 78.1% had avoided enucleation. Overall 43% of preserved eyes attained a visual acuity better than or equal to 6/12 and 55% achieved a visual acuity better than 6/60. There were four deaths due to retinoblastoma. Five patients were diagnosed with a second non-ocular malignancy. The most common treatment-related complications were cataracts, facial deformity, sepsis and febrile neutropaenia.

CONCLUSIONS

The introduction of newer globe-preserving treatments for retinoblastoma was associated with equivalent visual outcomes, stable mortality rate and a greater number of short-term complications but avoided the late side-effects associated with external beam radiotherapy.

Chemoreduction for intraocular retinoblastoma in Malaysia

In the last decade, chemotherapy in combination with focal therapy (chemoreduction) has been increasingly used in intraocular retinoblastoma to avoid enucleation and radiotherapy. The aim of this study was to assess the feasibility and outcome of chemoreduction in Malaysian children with retinoblastoma. This was a prospective study from August 2001 to January 2006. Twenty children (25 eyes) were given 4 cycles of chemoreduction, after which the response was assessed. Fourteen eyes showed a complete response, 10 eyes showed a partial response, and 1 eye had progressive disease. Twelve eyes developed progressive disease later, 9 after an initial complete response and 3 after a partial response. Overall, progressive disease occurred in 52%. There were 2 treatment failures, in Reese-Elsworth groups 3 and 4. Both eyes required enucleation. One eye in group 5 required second line chemotherapy to achieve a complete response. No eyes were irradiated. Five children (25%) defaulted follow-up, one of whom returned with disseminated disease. In conclusion, 4 cycles of chemoreduction achieved a durable complete response in only 12% of eyes. Chemoreduction is feasible in Malaysia but requires good patient compliance and close follow-up.

Macular Retinoblastoma: Evaluation of Tumor Control, Local Complications, and Visual Outcomes for Eyes Treated with Chemotherapy and Repetitive Foveal Laser Ablation

OBJECTIVE

To determine tumor control rates, complication rates, and visual acuity (VA) for patients with macular retinoblastoma undergoing systemic chemotherapy and foveal diode laser ablation.

DESIGN

Noncomparative retrospective case series.

PARTICIPANTS

All patients with retinoblastoma in the macula at the Bascom Palmer Eye Institute between 1991 and 2004 were evaluated. Patients included in the study were managed by the same clinician with a planned therapeutic strategy.

METHODS

Patients with Reese-Ellsworth groups I to IV disease underwent 4 to 9 cycles of systemic chemotherapy with vincristine, etoposide, and carboplatin, and patients with group V disease underwent 6 to 10 cycles with or without cyclosporine. All tumors underwent repetitive diode laser ablation (2-24 sessions) applied to the foveal and extrafoveal portions of tumors at each visit until tumors were deemed inactive for at least 6 months.

MAIN OUTCOME MEASURES

Recurrence requiring external beam radiation therapy or enucleation; VA; and complications including iris atrophy, peripheral focal lens opacity, peripheral anterior synechiae, and foveal neovascular membrane.

RESULTS

Forty-four eyes of 33 patients were treated. Eyes were classified as Reese-Ellsworth group I (1 [2%]), II (6 [12%]), III (3 [7%]), IV (5 [9%]), or V (29 [67%]). Thirty-eight eyes (86%) had successful tumor control and avoided enucleation at a median follow-up of 36 months. At 3 years, tumor control rates were 100% for Reese-Ellsworth groups I to IV and 83% for group V. All eyes requiring enucleation were in Reese-Ellsworth group V. No eyes required external beam radiation. The most common complications were iris atrophy (61%) and focal lens opacity (14%). Strabismus was noted in 16% of eyes. Snellen VA measured 20/40 or better in 36% of eyes, 20/80 or better in 57%, and 20/400 or better in 86%. An increasing number of laser applications and chemotherapy cycles was not associated with decreased VA, strabismus, or development of an afferent pupillary defect but was associated with development of local complications.

CONCLUSIONS

A unique approach to the application of diode laser therapy characterized by repetitive foveal treatments and aggressive chemotherapy resulted in tumor control rates that exceed those previously published. Furthermore, despite laser application directly to the fovea, 57% of patients retained 20/80 or better vision.

Retinoblastoma in Taiwan: the effect of a government-sponsored national health insurance program on the treatment and survival of patients with retinoblastoma

PURPOSE

To assess the effect of a government-sponsored national health insurance program that was implemented in Taiwan in March 1995 on the diagnosis and survival of patients with retinoblastoma.

PATIENTS AND METHODS

A retrospective chart review of 108 retinoblastoma patients who were treated at the Chang-Gung Medical Center, Taipei, Taiwan, from 1978 to 2003 was performed. Patients diagnosed and treated before March 1995 were compared with those treated after March 1995 in terms of annual number of cases, gender, laterality, age at onset, presenting signs, treatment modalities, and survival rate.

RESULTS

The average annual number of cases doubled from 3.3 to 6.5 after the implementation of the national health insurance program, and the age at diagnosis decreased from 29 to 21 months (P = .03). The most common presenting sign was leukocoria in both groups. The Kaplan-Meier survival rate at 5 years increased from 67% to 72%, an effect that was obvious in unilateral cases (70% to 83%) but not in bilateral cases (50% for both time periods).

CONCLUSIONS

The establishment of a government-sponsored national health insurance program in Taiwan allowed retinoblastoma to be diagnosed earlier, resulting in better survival rates, especially in unilateral cases.

Ocular presentations of breast cancer

CONTEXT

Breast cancer is the most common malignancy in women, with increasing incidence in Europe and North America. The frequency of involvement of the eye and visual pathways is reported to be as high as 30% in patients with known metastatic disease. In some cases, ophthalmic involvement can be the first sign of metastatic spread. Metastasis occurs via the haematogenous route and predominantly involves the choroid. Metastases to other ocular structures, the orbit and the visual pathways have also been described. Paraneoplastic effects are rare but significant.

TREATMENTS

Different modalities are employed in the treatment of breast cancer and its metastases. These include chemotherapy and radiotherapy. The ocular adverse effects of these have been well described, but recently developed new treatment modalities, such as monoclonal antibodies, may have different side-effects. With the increasing incidence of breast cancer and the advent of new treatment strategies, the complications of the disease and the sequelae of therapy are highly relevant to both oncologists and ophthalmologists.

Retinoblastoma in Nepal: a clinical profile of 30 cases

To determine the clinical profile of retinoblastoma and to provide baseline data for further studies on this subject. Prospective evaluation of 30 consecutive patients with retinoblastoma admitted at the B. P. Koirala Lions Center for Ophthalmic Studies, Kathmandu, Nepal, between October 1998 and July 2000 was carried out. Age, sex, laterality and time from onset of symptoms to diagnosis (lag time) were noted. Ancillary tests were undertaken to rule out metastasis. Male to female ratio was 1.1:1 and the median age of presentation was 3.1 years. Of 30 cases, 23 (76.6%) had unilateral involvement. Leukocoria was the presenting sign in 13 cases (43.3%) and fungating mass in 10 cases (33.3%). In 11 (36.7%), the latency period from onset of symptoms to diagnosis was 6-12 months. In bilateral cases, advanced disease was treated surgically and the fellow eye was treated with cryotherapy, photocoagulation and chemotherapy. Histopathological examination of 21 (70.0%) enucleated/exenterated cases revealed a poorly differentiated type of retinoblastoma. This is the first study of retinoblastoma from Nepal. Early diagnosis of this disease when it is localized to the eye is important to salvage the life of the child. An informational program directed toward the public in general, as well as careful screening of any white pupillary reflex by the pediatrician and/or primary health worker will encourage and support early diagnosis.

VITREORETINAL COMPLICATIONS OF RETINOBLASTOMA TREATMENT

PURPOSE

To describe complications of the retina and vitreous occurring in children undergoing treatment for retinoblastoma and their clinical management.

METHODS

Retrospective analysis of Ret-Cam images of 206 patients with retinoblastoma treated at one center between 1996 and 2003. Images were studied for vitreoretinal features other than tumor persistence or recurrence. Specifically, complications such as vitreous, retinal, or choroidal hemorrhage, retinal detachment, retinal fold, vascular obstruction, and preretinal or subretinal proliferation were sought.

RESULTS

Vitreoretinal complications of retinoblastoma therapy were identified in 14 patients (6.8%) All had heritable bilateral retinoblastoma. Group 5 Reese-Ellsworth disease was present in 50% (n = 7). All patients had systemic chemotherapy, 50% had external beam radiotherapy, and 64% had more than one local treatment method. Of the 14 patients with a complication, 4 eyes were enucleated for massive recurrence of tumor, 5 eyes were observed, and 5 eyes were treated successfully with vitreoretinal surgery for tractional or rhegmatogenous retinal detachment.

CONCLUSION

Vitreoretinal complications occurred in 6.8% of patients undergoing therapy for retinoblastoma. These included retinal tears, rhegmatogenous and tractional retinal detachment, subretinal fibrosis, vitreous traction bands, preretinal fibrosis, and pseudo-vitreous seeding. They were more often seen when systemic chemotherapy was combined with external beam radiation, cryotherapy, and local chemotherapy.

PARS PLANA VITRECTOMY IN EYES TREATED FOR RETINOBLASTOMA

BACKGROUND

As conservative treatments for retinoblastoma become more prevalent, there will be a greater number of ocular complications developing in eyes that previously would have been enucleated. Pars plana vitrectomy (PPV) is needed to manage some of these complications.

METHODS

The authors evaluated three consecutive cases of PPV in eyes that were successfully treated for retinoblastoma from the Retina Service of the Massachusetts Eye and Ear Infirmary (MEEI) performed between 1989 and 2004. A review of the literature to date regarding PPV after treatment for retinoblastoma was also performed.

RESULTS

There was no tumor reactivation in the three cases at MEEI. Vision was maintained at light perception in one case, and there was improvement in vision from hand motions to 20/80 and 20/400 to 20/160 in two cases. Twelve of the 24 cases reviewed in the literature were found to have significant complications of recurrent tumor, need for enucleation, and/or systemic metastasis.

CONCLUSION

PPV is associated with significant risks in eyes previously treated for retinoblastoma and should be reserved for monocular patients with no other alternative for retaining visual function. Areas that may influence outcome include different treatment modalities and length of time of documented tumor inactivity before PPV.

Metastatic RetinoblastomaClinical Features, Treatment, and Prognosis

PURPOSE

To evaluate the clinical features, treatment, and prognosis in patients with metastatic retinoblastoma.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Eighteen consecutive patients with metastatic retinoblastoma who were diagnosed and managed at the Oncology Service of Ankara University, Turkey, between January 1999 and January 2005.

METHODS

All patients underwent magnetic resonance imaging (MRI) of the orbit and brain, lumbar puncture, bone marrow aspiration, and bone scintigraphy for metastatic evaluation. Histopathologic confirmation of retinoblastoma via enucleation, exenteration, or orbital biopsy was obtained in each patient. The status of extraocular spread (optic nerve, extrascleral extension, or both) was assessed based on histopathologic or MRI results. Systemic treatment for metastatic retinoblastoma consisted of chemotherapy and radiotherapy (craniospinal, orbital, or both), if necessary.

MAIN OUTCOME MEASURES

Status of extraocular spread, site of metastasis, and survival from metastatic retinoblastoma.

RESULTS

At presentation, the mean patient age was 45 months (range, 13-86). Ten patients had unilateral retinoblastoma, 7 had bilateral retinoblastoma, and 1 had trilateral retinoblastoma. All patients with metastatic retinoblastoma had histopathologic or MRI evidence of unilateral extraocular disease characterized by optic nerve involvement, extrascleral extension, or both. Nine of 18 patients experienced central nervous system (CNS) involvement, 5 patients had distant and CNS metastasis, and 4 patients had distant metastasis only. Fourteen patients underwent craniospinal irradiation and 12 had orbital irradiation. At a mean follow-up of 24 months (range, 4-62), all patients with CNS and concurrent distant and CNS metastasis were deceased. Four patients who had distant metastasis only were alive at a follow-up ranging from 9 to 62 months.

CONCLUSIONS

The prognosis for metastatic retinoblastoma is dismal and the presence of CNS involvement may portend an even worse outcome.

Diagnosis and current management of retinoblastoma

Retinoblastoma represents the prototypic model for inherited cancers. The RB1 gene was the first tumor suppressor gene to be identified. It represents the most frequent primary eye cancer in children under 15 years old, habitually occurring in infancy, even in utero, but can be observed in older children or young adults. Many other retinal lesions may also simulate retinoblastoma. The two major presenting signs are leukocoria and strabismus, but other ocular or general signs may be observed. A highly malignant tumor, retinoblastoma can nowadays be cured. The heritable form, however, carries a high risk of second nonocular tumors. Treatment in the early stages of disease holds a good prognosis for survival and salvage of visual function. In very late stages, however, the prognosis for ocular function and even survival is jeopardized.

Retinoblastoma

Retinoblastoma is a rare eye tumor of childhood that arises in the retina. It is the most common intraocular malignancy of infancy and childhood; with an incidence of 1/15,000–20,000 live births. The two most frequent symptoms revealing retinoblastoma are leukocoria and strabismus. Iris rubeosis, hypopyon, hyphema, buphthalmia, orbital cellulites and exophthalmia may also be observed. Sixty per cent of retinoblastomas are unilateral and most of these forms are not hereditary (median age at diagnosis two years). Retinoblastoma is bilateral in 40% of cases (median age at diagnosis one year). All bilateral and multifocal unilateral forms are hereditary. Hereditary retinoblastoma constitutes a cancer predisposition syndrome: a subject constitutionally carrying an RB1 gene mutation has a greater than 90% risk of developing retinoblastoma but is also at increased risk of developing other types of cancers. Diagnosis is made by fundoscopy. Ultrasound, magnetic resonance imaging (MRI) and computed tomography (CT) scans may contribute to diagnosis. Management of patients with retinoblastoma must take into account the various aspects of the disease: the visual risk, the possibly hereditary nature of the disease, the life-threatening risk. Enucleation is still often necessary in unilateral disease; the decision for adjuvant treatment is taken according to the histological risk factors. Conservative treatment for at least one eye is possible in most of the bilateral cases. It includes laser alone or combined with chemotherapy, cryotherapy and brachytherapy. The indication for external beam radiotherapy should be restricted to large ocular tumors and diffuse vitreous seeding because of the risk of late effects, including secondary sarcoma. Vital prognosis, related to retinoblastoma alone, is now excellent in patients with unilateral or bilateral forms of retinoblastoma. Long term follow-up and early counseling regarding the risk of second primary tumors and transmission should be offered to retinoblastoma patients.

Retinoblastoma in Turkey: survival and clinical characteristics 1981-2004

BACKGROUND

In this study, the authors aim to describe the survival and clinical characteristics of 141 retinoblastoma cases treated at Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey, between 1981 and 2004.

METHOD

The authors retrospectively analyzed the clinical records of 141 children (177 eyes) diagnosed with retinoblastoma and treated between 1981 and 2004. Information on gender, laterality, age at diagnosis, presenting signs, spread of tumor, treatment modality, survival rate, and family history were collected.

RESULTS

A total of 105 cases (74.5%) were unilateral and 36 cases (25.5%) were bilateral. The mean age overall at the time of diagnosis was 25 months; in unilateral cases, 29 months; and in bilateral cases, 16 months. The most common presenting signs were leukocoria (116 cases, 82%), strabismus (14 cases, 10%) and proptosis (11 cases, 8%). A total of 28 cases had orbital extension, nine patients had central nervous system invasion, and five cases exhibited bone marrow involvement. In total, 16 patients (11%) had a family history of retinoblastoma. One case developed a secondary neoplasm. The 3 year cumulative survival rate of 141 patients was 89.69% (unilateral, 90.74%; bilateral 87.35% P = 0.9371, P > 0.05, log rank test).

CONCLUSION

The study's survival rate was similar to developed countries. The success in higher survival rates is based on the authors multidisciplinary team approach done by the same group and the support of the authors' clinic and government in sponsoring the medical insurance of all patients.

[Conservative treatment in patients with unilateral retinoblastoma]

THE AIM of our study was to evaluate results of conservative treatment of patients with unilateral retinoblastoma.

MATERIAL AND METHODS

Twenty one patients, 11 boys and 10 girls aged 2 months to 4, 5 years (median age 1 year) were studied. Local disease advancement according to Reese-Elsworth was defined in all patients. Neoadjuvant chemotherapy consisting of Vincristine, Etoposide and Carboplatin was administered. After every 2 courses tumour response was evaluated. Sixteen patients were treated with chemotherapy alone. Local treatment including brachytherapy, thermochemotherapy and cryotherapy was implemented and the choice of the method depended on the tumour's localization, size and response to chemotherapy. Statistical analysis using demographic data and survival curves were performed.

RESULTS

On completion of treatment all patients achieved tumour regression. Eleven patients are progression free with a follow-up from 10 months to 6 years 4 months (median--2 yrs 5m). In 10 patients relapse was observed. A total of seven enucleations were performed in the examined group. In histopathological examination viable tumour cells were present in all removed eye balls. Distant metastases were not observed in any of these patients. All patients are alive with a follow-up from 10 months to 9 yrs 6 months (median--4 yrs 7 months) from diagnosis. Disease free survival and ocular survival is 44% and 54% respectively.

CONCLUSION

Neoadjuvant chemotherapy in unilateral retinoblastoma allows to avoid enucleation in some patients.

[Two cases of retinal hemangioma treated by transpupillary thermotherapy]

PURPOSE

To evaluate transpupillary thermotherapy(TTT), the treatment was reviewed in two cases of retinal hemangioma which resisted photocoagulation. CASE 1: A 25-year-old man was referred to us for visual impairment in his right eye caused by retinal hemangioma. Although photocoagulation had been performed once in a previous hospital, the treatment was unsuccessful. His visual acuity was 0.1 OD. Ophthalmoscopic examination revealed a hemangioma located in the superotemporal peripheral retina with serous retinal detachment. We performed photocoagulation of the afferent artery and TTT of the hemangioma two times each. The hemangioma regressed and the serous retinal detachment resolved. The patient's visual acuity OD improved to 0.2. CASE 2: A 13-year-old girl was referred to us for visual impairment in her right eye caused by retinal hemangioma. Photocoagulation had been performed five times in a previous hospital, but the treatment was unsuccessful. Her visual acuity was 0.05 OD. Opthalmoscopic examination revealed a hemangioma located in the inferonasal peripheral retina with serous retinal detachment. We performed photocoagulation of the afferent artery two times and TTT of the hemangioma four times. The hemangioma regressed and the serous retinal detachment resolved.

CONCLUSION

TTT is performed with a larger spot size, a longer wavelength, and a longer duration than photocoagulation. TTT could be an effective treatment for retinal hemangioma.

Treatment of retinoblastoma patients with chemoreduction plus local therapy: experience of the AC Camargo Hospital, Brazil

To evaluate the efficacy of conservative management of intraocular retinoblastoma with chemoreduction combined with local therapy with or without plaque radiation in the preservation of the eye, and avoidance of external beam radiation therapy (EBRT) (success rate). From 1995 to 2000, 84 newly diagnosed patients with intraocular retinoblastoma were admitted to the Pediatric Department of the Hospital do Cancer A.C. Camargo, São Paulo, Brazil. All children were treated with 2 to 6 cycles of chemotherapy (carboplatin, vincristine, and etoposide) plus local therapy (cryotherapy, laser photocoagulation, and thermotherapy), or plaque radiation therapy during and/or after the chemotherapy. The Mann-Whitney test was used to compare means of quantitative variables. The chi test or the Fisher exact test were employed to verify the association between the outcome and the independent variables. For all tests alpha=5% was adopted. Success rate was higher for patients with bilateral tumors (54%) than for children with unilateral tumors (19%) (P=0.003). For patients with Reese-Ellsworth stages I, II, and III, no statistically significant differences in the success rates were noted in the group of unilateral (50%) and bilateral tumors (79.1%) (P=0.179). Among children with Reese-Ellsworth stages IV and V, the success rate was significantly higher for patients with bilateral tumors (40.7%) than for those with unilateral (0%) (P=0.012). Chemoreduction combined with local therapy, with or without plaque radiotherapy, is efficacious in avoiding enucleation and the use of external beam radiation therapy for children with intraocular retinoblastoma.

Late-Onset Retinoblastoma in a Well-Functioning Fellow Eye

PURPOSE

To describe the documented growth, clinical course, and histopathology of retinoblastomas in an untreated and otherwise normal right eye of a 27-year-old white male with a g.153211T>A (p.Tyr606X) mutation in the retinoblastoma 1 gene, whose left eye was enucleated at age 2 years for 2 retinoblastomas.

DESIGN AND PARTICIPANTS

Retrospective interventional case report.

INTERVENTIONS

Over the years, the right eye was irradiated twice and underwent trans-pars plana vitrectomy, transscleral cryocoagulation, argon laser photocoagulation of tumors and their feeder vessels, extracapsular cataract extraction with posterior chamber lens implantation, and neodymium:yttrium-aluminum-garnet laser treatment of after-cataract in the form of Elschnig's pearls. Finally, the patient received combination chemotherapy with etoposide, methotrexate, actinomycin D, cisplatin, and vincristine.

RESULTS

The eye finally had to be removed 12 years later due to tumor recurrences and seeding, pseudohypopyon, and elevated intraocular pressure. Histopathology showed microcellular retinoblastoma cells in the anterior chamber angle and trabecular meshwork without subconjunctival extension and in the nasal ciliary body, pars plana, internal limiting membrane, and optic nerve head anterior to the cribriform plate. The patient is without local or systemic recurrences at age 50, 11 years after the last eye was enucleated.

CONCLUSIONS

This report shows that retinoblastoma patients may have tumor growth in their fellow eye 25 years after the first eye and also that Elschnig's after-cataract pearls still can arise after irradiation of a lens with 45 Gy.

Combined local treatment and chemotherapy in the management of bilateral retinoblastomas in Hungary

This retrospective study supports that brachytherapy combined with cytostatic therapy may effectively contribute to tumor control. The second eye of 13 patients with bilateral retinoblastoma was treated with plaque brachytherapy after the enucleation of the first eye. Eleven patients received systemic cytostatic therapy. The mean follow up was 60 (+/-42 SD) months. Twelve patients are alive and free of tumor, 8 of them with acceptable visual acuity. After cytostatic therapy, late nephropathy was observed in 2 patients. In conclusion, brachytherapy combined with cytostatic therapy will be an option in the management of bilateral retinoblastoma after the enucleation of the first eye.

Vitreous relapse following primary chemotherapy for retinoblastoma: is adjuvant diode laser a risk factor?

AIMS

To evaluate rates of vitreous relapse among retinoblastoma patients treated with primary chemotherapy and assess diode laser as a potential risk factor for relapse.

METHODS

Retrospective review of all patients treated with primary chemotherapy at a large ocular oncology centre. Eyes that developed vitreous relapse were coded with regard to Reese-Ellsworth Group, laterality, time to relapse, type of relapse (vitreous base or non-vitreous base relapse), treatments used (including adjuvant diode laser), and ocular preservation. Individual tumour foci treated with laser hyperthermia were also coded for laser parameters including power settings, number of treatments, and concomitant administration of systemic chemotherapy (chemothermotherapy).

RESULTS

15 of 106 eyes (14.15%) developed vitreous relapse over a 6 year period. Mean time to relapse was 7.2 months after chemotherapy was completed. Five cases (33%) were of the vitreous base variety. Ocular salvage was attempted in 11 cases using a variety of methods; one patient was lost to follow up. Six of the remaining 10 eyes (60%) were salvaged. Eight of 38 eyes (21%) treated with systemic chemotherapy and laser hyperthermia developed vitreous relapse compared with seven of 68 eyes (10%) treated with primary chemotherapy alone (p<0.005). Laser settings, number of hyperthermia treatments, and the concomitant use of systemic chemotherapy (chemothermotherapy) were not associated with higher rates of vitreous relapse.

CONCLUSION

Nearly one in seven eyes with retinoblastoma treated with primary chemotherapy may develop vitreous relapse. The administration of diode laser hyperthermia appears to increase this risk. Despite additional therapy a number of these eyes succumb to enucleation.

Retinoblastoma: a proposal for a multimodal treatment concept for intraocular retinoblastoma in Austria

Retinoblastoma is the most common intraocular malignancy in childhood. If confined to the globe and managed with current treatment strategies, more than 90% of children survive with preservation of vision in at least one eye, even in bilateral retinoblastoma. Enucleation of the involved eye in unilateral retinoblastoma and of the more involved eye in bilateral disease, together with external beam radiotherapy in advanced bilateral retinoblastoma, formed the two cornerstones of treatment for many years and led to an increase in survival to over 90%. In the early 1990s the extent of the risk of second cancers in the field of radiation became known, the risk increasing by 10% per decade of life. As a consequence, chemotherapy-based regimens were developed as alternative treatments. During the past ten years retinoblastoma treatment has fundamentally changed, with a trend away from enucleation and external beam radiotherapy towards conservative treatments aiming at preservation of the affected globe(s) in selected patients. Systemic neoadjuvant chemotherapy induces tumor regression (chemoreduction), and residual regressed tumor is then treated focally with, for example, transpupillary thermotherapy, cryotherapy and plaque radiotherapy (consolidation). Between 1984 and 2004, 27 patients were treated at the department of ophthalmology in collaboration with the department of pediatrics at the Medical University of Graz. Before 2001, the affected eyes of all patients with unilateral retinoblastoma were enucleated (10 of 10), as were 6 of 7 of the more involved eyes of patients with bilateral disease. A globe-sparing strategy was introduced in 2001 and since then eligible patients have been treated with chemoreduction and focal therapy; 2 of 5 eyes with unilateral disease were salvaged, and both eyes of a patient with bilateral disease. We discuss current treatment options and present a proposal for the management of intraocular retinoblastoma in children in Austria, the Austrian retinoblastoma study, RB A-2003.

Atrophic chorioretinal scar and focal scleral bowing following thermochemotherapy with a diode laser for retinoblastoma

One of the treatment options for intraocular retinoblastoma is thermochemotherapy with diode laser combined with chemotherapy. Very little is known about the evolution of laser scars resulting from diode laser treatment for retinoblastoma. We report a case of atrophic chorioretinal scar and focal scleral bowing after thermochemotherapy with diode laser for retinoblastoma.

Retinoblastoma

Retinoblastoma, a neuroblastic tumor, is the most common primary intraocular malignancy of childhood. Patients usually present with leukokoria (white reflex or white pupil), detected in primary care. The mean age at diagnosis is 12 months for bilateral tumors and 24 months for unilateral tumors. If untreated, almost all patients die of intracranial extension and disseminated disease within two years. However, new diagnostic and treatment methods allow for a high cure rate (93 percent five-year survival in the United States), therefore it is important that primary care physicians recognize the manifestations of this malignancy. Diagnosis is primarily by history and complete ophthalmic examination, with studies including ultrasonography of the eye and imaging of the orbits and brain. Treatment modalities include laser thermotherapy, cryotherapy, radioactive plaques, external beam radiotherapy, chemotherapy, and enucleation. Prospective parents with a family history of retinoblastoma should be referred for genetic counseling. Office evaluation for a red reflex in children should be performed until three years of age. If leukokoria is observed, the patient should be examined by an ophthalmologist within one week.

Hamartome combiné de l’épithélium pigmentaire et de la rétine

INTRODUCTION

Combined hamartoma of the retina and retinal pigment epithelium is a rare condition, characterized by a proliferation of the retinal pigmentary epithelium and retinal gliosis leading to a disorganization of the retina and papilla. This study aimed to demonstrate the advantages of early diagnosis and regular monitoring.

OBSERVATIONS

We report a series of four children followed between 2001 and 2004 with combined hamartoma of the retina and retinal pigment epithelium, with age of diagnosis ranging from 3 months to 8 years. The main reason for consultation was reduction of vision. The clinical examination objectified the existence of a slightly grayish peripapillary formation with tortuous retinal vessels. This condition was confirmed by angiography with fluorescein in three cases and by optical coherence tomography (OCT) in one case. Progression showed the persistence of low vision in all four cases and the appearance of a neovascular membrane in one case.

DISCUSSION

Combined hamartoma of the retina and retinal pigment epithelium is probably a congenital tumor whose pathogenesis has not yet been elucidated. The diagnosis is clinical and the patient can be thoroughly examined by retinal angiography and optical coherence tomography (OCT). In this disorder, it is important to eliminate retinoblastoma and malignant melanoma of the choroid, showing the advantage of radiological exploration. Progression is stationary; nevertheless a reduction in visual acuity can be related to an epiretinal membrane or a neovascular membrane.

CONCLUSION

Knowledge of the clinical aspect is essential to differentiate this condition from the malignant retinal processes. This tumor can progress in spite of its benign character. Regular follow-up is essential and can improve the visual prognosis.