Survival of retinoblastoma in less-developed countries impact of socioeconomic and health-related indicators

Extraocular retinoblastoma in Indian children: clinical, imaging and histopathological features

AIM

TO STUDY EYES WITH EXTRAOCULAR DISSEMINATION (EORB), WITH THE FOLLOWING AIMS: first to establish the mean lag period and to understand various reasons for delayed presentation, second to study their imaging profiles and third to analyze histopathological features of eyes enucleated after neoadjuvant chemotherapy.

METHODS

Prospective study of clinical and imaging features of EORBs (stage III and IV International Retinoblastoma Staging System) presenting to a tertiary eye care centre. Histopathological features of eyes enucleated after receiving neoadjuvant chemotherapy were analyzed. A pictorial illustration of the varied imaging profile of EORB was also presented.

RESULTS

Over a period of one year, 97 eyes were diagnosed with retinoblastoma; 32 children (36 eyes) (37.1%) had EORB. Mean age 3.6±1.9 years, 71.9% males, 71.9% unilateral, 3.1% with positive family history and 40.6% with metastasis. On imaging, there was extrascleral involvement in 22.2%, involvement of orbital part of optic nerve in 33.3%, involvement of central nervous system in 27.8% and orbital wall involvement in 2.9% eyes. On histopathological analysis of eyes enucleated after neoadjuvant chemotherapy, 25.0% had no residual viable tumour tissue and rest all tumours were poorly differentiated.

CONCLUSION

There are very few human malignancies where definitive treatment is started without any confirmed histopathological diagnosis and imaging plays an important role in diagnosis and appropriate staging of the disease. Chemotherapy has a variable effect on EORB, 75.0% of eyes with EORB had residual viable tumour tissue when enucleated after receiving neoadjuvant chemotherapy.

SIOP-PODC recommendations for graduated-intensity treatment of retinoblastoma in developing countries

Retinoblastoma remains incurable in many regions of the world. The major obstacles to cure are delayed diagnosis, poor treatment compliance, and lack of evidence-based recommendations for clinical management. Although enucleation is curative for intraocular disease, in developing countries retinoblastoma is often diagnosed after the disease has disseminated beyond the eye. A SIOP-PODC committee generated guidelines for the clinical management of retinoblastoma in developing countries and developed a classification system based on the resources available in those settings. Recommendations are provided for staging and treatment of unilateral and bilateral retinoblastoma and counseling of families for whom compliance is an issue.

[Retinoblastoma: inventory in Mali and program to develop early diagnosis, treatments and rehabilitation]

Retinoblastoma (RB) is a rare embryonic tumour that represents 1/16,000 births in France. In Mali, a study showed the characteristics of a hospital series of cases seen in Bamako in the Pediatric Oncology Unit of Gabriel Touré Teaching Hospital and in the Tropical Ophthalmology Institute of Africa (IOTA) between January 2005 and June 2007. Median age was 4 years versus 2 years in France for unilateral disease. Near two third of children with RB had extra-ocular extension at diagnosis, which is now exceptional in France. Only 11% were bilateral versus 35% in France. Cure rate was around 50%, but it is estimated only on the cases arriving in Bamako and with at least 20% lost of follow-up. Cure rate is over 95% in France within an exhaustive register. RB appears as an exemplary tumor and rapid improvements could be obtained in low-income countries with relatively limited means. This is why, the Alliance mondiale contre le cancer (AMCC), the Institut Curie in Paris, which is the reference center in France for RB, and teams in Bamako were proposing a program to help the development of early diagnosis, treatments, including eye preservation, and rehabilitation of children with RB in sub-Saharan Africa in collaboration with the Groupe franco-africain d'oncologie pédiatrique (GFAOP). The official launching of this program was held in Bamako November 4, 2011 for Mali and the surrounding regions. After this first experience, this program is now implemented in other countries.

Histopathology of retinoblastoma: does standardization make a difference in reporting?

The International Retinoblastoma Staging Working Group (IRSWG) provided guidelines for tissue handling of eyes enucleated for retinoblastoma. We adopted these guidelines from January 2009. Reviewing histopathology slides between January 2006 and December 2010 we found significantly more number of eyes with massive choroidal, optic nerve, and anterior segment invasion by tumor cells in the post-IRSWG era. The guidelines provided by the IRSWG; in addition to being standardized; recognize more eyes with histopathologic risk factors compared to techniques applied in the past. This may translate to more children receiving adjuvant chemotherapy and contribute to reduced mortality rates in the future.

Direct costs for retinoblastoma treatment during the first year of comprehensive therapy in China

PURPOSE

To evaluate the direct costs and analyze the potential cost-driving factors in the first year of retinoblastoma treatment in China.

METHODS

Sixty-nine pediatric patients who received multidisciplinary treatment for retinoblastoma in three tertiary hospitals from 2006 to 2011 were included in this retrospective study. The direct costs, including costs for chemotherapy, focal therapy, anesthetic procedure, enucleation, fundus examination, hospitalization and outpatient appointment, transportation, and accommodation for family members, were obtained from medical records and interviews.

RESULTS

The average direct costs for retinoblastoma treatment was U.S. $9,422 ± 3,709 per patient during the first year. Of this amount, chemotherapy-related expenses were $2,991 ± 3,083 (31.74%), transportation and accommodation expenses were $2,560 ± 1,348 (27.17%), general anesthetic procedure was $1,081 ± 2,711 (11.48%), and enucleation was $900 ± 1,015 (9.56%). The costs for intra-arterial chemotherapy ($1,224 ± 754) and chemotherapy drugs ($517 ± 134) were major components in chemotherapy-related expenses. The retinoblastoma clinical stage and family income positively correlated with the total direct costs (P = .0358 and .0185, respectively).

CONCLUSION

Comprehensive treatment involving chemotherapy imposes an enormous economical burden on families affected by retinoblastoma in China.

Retinoblastoma

Retinoblastoma is an aggressive eye cancer of infancy and childhood. Survival and the chance of saving vision depend on severity of disease at presentation. Retinoblastoma was the first tumour to draw attention to the genetic aetiology of cancer. Despite good understanding of its aetiology, mortality from retinoblastoma is about 70% in countries of low and middle income, where most affected children live. Poor public and medical awareness, and an absence of rigorous clinical trials to assess innovative treatments impede progress. Worldwide, most of the estimated 9000 newly diagnosed patients every year will die. However, global digital communications present opportunities to optimise standards of care for children and families affected by this rare and often devastating cancer. Parents are now leading the effort for widespread awareness of the danger of leucocoria. Genome-level technologies could make genetic testing a reality for every family affected by retinoblastoma. Best-practice guidelines, online sharing of pathological images, point-of-care data entry, multidisciplinary research, and clinical trials can reduce mortality. Most importantly, active participation of survivors and families will ensure that the whole wellbeing of the child is prioritised in any treatment plan.

"Retinoblastoma survival disparity": The expanding horizon in developing countries

The patients' survival for the most common intraocular tumor in children, retinoblastoma, has a wide spectrum among the world countries. This study was conducted to provide an overview of the retinoblastoma survival disparity worldwide by discussing the trends of patients' survival, as well as recent advances in the management of retinoblastoma. The design of this study was literature review and commentary. Selected articles from PubMed (except one) including both developing and developed countries regarding the patients' survival in retinoblastoma were considered and reviewed critically. An analysis of 47 articles was performed. In conclusion, in spite of an obvious contrast of retinoblastoma survival disparity in the world, the expanding horizons in developing countries are promising and continuing on all fronts and results are hope-inspiring.

Clinical presentation of retinoblastoma in a middle-income country

The presenting features of retinoblastoma in developing countries and their correlation with disease stage and patient survival are poorly known and they may be useful as background information for planning early diagnosis initiatives. Therefore, we undertook a retrospective review of 508 patients (467 evaluable, 296 unilateral) treated in Argentina from 1988 to 2008. Patients presented at an older age than reported from high-income countries [mean age 24 mo (range, 0 to 165 mo), 31 mo for unilateral (range, 0 to 165 mo), and 13.3 mo (range, 0 to 62 mo) for bilateral disease]. Leukocoria was the most common presenting sign (n=402, 86%). Strabismus was the only complaint in 25 (5.3%) patients. Forty-two patients (9%) presented with an enlarged eyeball and 37 (7.9%) with a red eye. Retinoblastoma was diagnosed in 22 (4.7%) asymptomatic children. These patients and those with strabismus alone were significantly younger and had a significantly better survival. Children presenting with enlarged eyeballs were significantly older and had significantly lower survival. In multivariable analysis older age and presentation with enlarged eyeballs were independently associated to advanced stage and mortality (P<0.001). Retinoblastoma is diagnosed in later stages in our setting and presentation with eye enlargement and increasing age at diagnosis correlate with worse outcome.

Outcome, pathologic findings, and compliance in orbital retinoblastoma (International Retinoblastoma Staging System stage III) treated with neoadjuvant chemotherapy: a prospective study

PURPOSE

The present study prospectively evaluated outcome, pathologic findings, and compliance in orbital retinoblastoma patients (International Retinoblastoma Staging System [IRSS] stage III).

DESIGN

Prospective study and case series.

PARTICIPANTS

Twenty-eight consecutive IRSS stage III retinoblastoma patients were enrolled prospectively in the study after ethics committee approval and written informed consent.

METHODS

Planned therapy for patients included treatment with a uniform protocol consisting of neoadjuvant chemotherapy followed by enucleation, adjuvant radiotherapy, and chemotherapy. Prospective computerized data entry and telephone contact were undertaken to improve compliance, a major issue in treatment of orbital retinoblastoma.

MAIN OUTCOME MEASURES

Event-free survival (EFS) and overall survival (OS) were calculated using Kaplan-Meier survival analysis. The difference between groups was analyzed using the log-rank test.

RESULTS

Median follow-up was 14.75 months (range, 2.23-26.3 months). The OS for all patients was 40.4% and the EFS was 33.33% at a follow-up of 26.3 months. The median EFS and OS were 10.37 months and 15.73 months, respectively. At baseline, bilateral retinoblastoma predicted inferior EFS (P = 0.0006) and OS (P = 0.0081). Twenty-two of 28 patients underwent enucleation, and viable tumor was present in 21 of 22 enucleated specimens (95%). Neoadjuvant chemotherapy prevented orbital exenterations. Presence of tumor in the cut end of the optic nerve significantly correlated with inferior EFS (P = 0.012) and OS (P = 0.0098). Central nervous system metastasis was the most common site of relapse and death. The overall rate of compliance with treatment was 67.8% (19/28), which was twice the compliance rate at the authors' center before initiation of the present study.

CONCLUSIONS

There is a paucity of information in the literature on outcomes and pathologic findings after neoadjuvant chemotherapy in IRSS stage III retinoblastoma treated with a uniform treatment protocol, and as far as the authors are aware, there has been no prospective study. Neoadjuvant chemotherapy was able to avoid exenteration in all operated patients; however, residual viable tumor was present in 95% of enucleated specimens. Bilaterality and tumor in the optic nerve cut end after neoadjuvant chemotherapy were associated with inferior outcome. Compliance could be improved with computerized data entry and regular telephone contact.

Understanding pRb: toward the necessary development of targeted treatments for retinoblastoma

Retinoblastoma is a pediatric retinal tumor initiated by biallelic inactivation of the retinoblastoma gene (RB1). RB1 was the first identified tumor suppressor gene and has defined roles in the regulation of cell cycle progression, DNA replication, and terminal differentiation. However, despite the abundance of work demonstrating the molecular function and identifying binding partners of pRb, the challenge facing molecular biologists and clinical oncologists is how to integrate this vast body of molecular knowledge into the development of targeted therapies for treatment of retinoblastoma. We propose that a more thorough genetic understanding of retinoblastoma would inform targeted treatment decisions and could improve outcomes and quality of life in children affected by this disease.

Analysis of aqueous humour proteins in patients with retinoblastoma

BACKGROUND

To investigate aqueous humour protein composition from retinoblastoma patients.

DESIGN

Prospective, hospital-based study.

PARTICIPANTS

Eighteen retinoblastoma patients (Reese-Ellsworth stage V or ABC classification group E RB) undergoing ocular enucleation, and 10 normal subjects undergoing cataract surgery. Five of 18 patients presented with associated secondary glaucoma whereas 13 had no secondary glaucoma; 5 of 13 patients with no secondary glaucoma received chemotherapeutical treatment with melphalan.

METHODS

Aqueous humour samples were collected by limbal paracentesis of the anterior chamber after ocular enucleation in patients and after the stab peripheral corneal incision in controls. Total protein concentration according to Bradford method and sodium dodecyl sulphate-polyacrylamide gel electrophoresis of the samples were performed.

MAIN OUTCOME MEASURE

Aqueous humour protein concentration.

RESULTS

Aqueous humour protein concentration was significantly higher in retinoblastoma patients than controls (P < 0.01); patients with secondary glaucoma presented the highest values (P < 0.05 vs. controls); patients treated with melphalan presented a significant decrease (P < 0.01) versus non-treated; controls did not significantly differ from treated patients. Sodium dodecyl sulphate-polyacrylamide gel electrophoresis pattern in retinoblastoma patients who did not receive any treatment was very different either from treated or from controls.

CONCLUSION

This study represents a preliminary step towards a more accurate two dimensional electrophoresis (2DE) pattern, which will be combined with mass spectrometry analysis to clarify the potential role of specific proteins in tumour development and progression; although these results suggest that aqueous humour protein pattern in retinoblastoma is characteristic, several aspects of the study are still under investigation.

Web-based survey of resources for treatment and long-term follow-up for children with brain tumors in developing countries

INTRODUCTION

Information about pediatric survivors of brain tumors in developing countries is scant.

PURPOSE

In this study, we aimed to investigate the availability of resources for treatment and long-term follow-up of children with central nervous system tumors in developing countries.

MATERIALS AND METHODS

A web-based questionnaire on available services and follow-up of brain tumor survivors was posted at www.cure4kids.org , and registered users were invited to participate.

RESULTS

A total of 140 evaluable responses from developing countries (n = 103) and high-income countries (n = 37) were obtained. There was a significant correlation between gross national income and the availability of services for treatment and follow-up and between patient load and the availability of some services.

CONCLUSION

The resources for treatment and long-term follow-up of children with brain tumors need to be improved in developing countries.

Bibliometric analysis on retinoblastoma literatures in PubMed during 1929 to 2010

AIM

To determine the growth rule and tendency of retinoblastoma (Rb) literature, and to provide the basis for research of diagnosis, treatment and on Rb.

METHODS

Bibliometric analyses were carried out on Rb literatures which contain the descriptors of Rb in their titles or texts from 1929 to 2010 in PubMed database (www.ncbi.nlm.nih.gov/Pubmed). The biomedical journals referring to Rb by using bibliometric indicators were calculated. The principal bibliometric indicators, i.e., Price's and Bradford's laws to the increase or distribution of scientific literature, the participation index of languages and the journals were applied. By means of manual coding, Rb documents were classified according to documents studied and to statistical analysis.

RESULTS

During 1929-2010, there were 16162 literatures in the PubMed database including the word Rb. According to the literature type, it includes Review (n=2026), Randomized Controlled Trial (n=7), Practice guideline (n=3), meta-analysis (n=4), letter (n=215), editorial (n=98), clinical trial (n=115) and others (n=13694). By the statistical analysis, its equation is near power index (y=3.0477x(2.6088), R(2)=0.9666). From 1929 to 2010, Rb literatures in English were primarily dominant (90.71%) and the amount of the literature in Chinese ranked the fourth (1.37%). By searching PubMed, 1420(8.8%) literatures covered were from 41 of 48 ophthalmological, and 406 (2.5%) literatures from 44 of 86 pediatrics journals that correlated with retinoblastoma (SCI-indexed). The data showed that the literatures of Rb were gradually increasing year by year and were approximate near power index during 1929-2010, and the document publishes published mainly in ophthalmological journals, and in English (90.71%), and showing that the study on Rb is a popular subject in the last half century.

CONCLUSION

The literatures of Rb are gradually increasing, mainly English in ophthalmologic journals.

Strategies to manage retinoblastoma in developing countries

Survival of retinoblastoma is >90% in developed countries but there are significant differences with developing countries in stage at presentation, available treatment options, family compliance, and survival. In low-income countries (LICs), children present with advanced disease, and the reasons are socioeconomic and cultural. In middle-income countries (MICs), survival rates are better (>70%), but there is a high prevalence of microscopically disseminated extraocular disease. Programs for eye preservation have been developed, but toxicity-related mortality is higher. Although effective treatment of microscopically extraocular disease improved the outcome, worldwide survival will be increased only by earlier diagnosis and better treatment adherence.

Epidemiology and Rb1 gene of retinoblastoma

Retinoblastoma (Rb) is the most common eye cancer in children and it can be inherited. Rb is quite rare and originators from the neural retina with a significant genetic component in etiology, which occurs in approximately 1 in every 20 0000 births. In children with the heritable genetic form of Rb, there is a mutation on chromosome 13, called the retinoblastoma 1 (Rb1) gene. Early diagnosis and intervention is critical to the successful treatment of the Rb. The Rb1 gene is the first cloned tumor suppressor gene. As a negative regulator of the cell cycle, Rb1 gene could maintain a balance between cell growth and development through binding to transcription factors and regulating the expression of genes involved in cell proliferation and differentiation. Thus, it is involved in cell cycle, cell senescence, growth arrest, apoptosis and differentiation. We summarized the recent advances on the epidemiology and Rb1 gene of Rb in this review.