Enucleation for retinoblastoma: the experience of a single center in Jordan

Treatment Outcomes and Definition Inconsistencies in High-Risk Unilateral Retinoblastoma

PURPOSE

To compare the clinical outcomes of children with unilateral retinoblastoma (Rb) and high-risk histopathology features (HRHF) following upfront enucleation with/without adjuvant chemotherapy, and investigate cases locally considered non-HRHF but converted to a standardized HRHF definition.

DESIGN

Retrospective multinational clinical cohort study.

METHODS

Children with Rb who presented to 21 centers from 12 countries between 2011-2020, and underwent primary enucleation were recruited. Centers retrieved clinical data and were asked to report detailed histopathology findings, as well as indicate cases defined locally as high-risk. For analysis, only unilateral cases with standardized HRHF, defined as retrolaminar optic nerve invasion, massive choroidal invasion, scleral invasion, anterior-segment involvement, and/or combined nonmassive choroidal and prelaminar/laminar optic nerve invasion, were included. Main outcome measures included orbital tumor recurrence, systemic metastasis, survival and number, and outcome of cases converted to standardized HRHF.

RESULTS

A total of 600 children presenting to 14 centers in 9 countries were included. Of these, 505 (84.2%) were considered locally as HRHF and received adjuvant chemotherapy. After a median follow-up period of 39.2 ± 1.6 months (range: 0.8-60.0 months), 36 (6.0%) had orbital tumor recurrence, 49 (8.2%) metastasis, and 72 (12.0%) children died. Children not receiving adjuvant chemotherapy were at significantly increased risk of orbital tumor recurrence, metastasis, and death (P ≤ .002). Of the study children, 63/600 (10.5%) were considered locally non-HRHF, but converted to standardized HRHF and included in the analysis. Of these, 6/63 (9.5%) had orbital tumor recurrence, 5/63 (7.9%) metastasis, and 6/63 (9.5%) children died. Isolated minor choroidal invasion with prelaminar/laminar optic nerve invasion was reported in 114 (19.0%) children, but considered locally as HRHF only in 68/114 (59.6%). Of these, 6/114 (5.3%) children developed metastasis and subsequently died, yielding a number needed to treat of 15.

CONCLUSION

Based on this multinational cohort of children with Rb, we recommend the use of adjuvant chemotherapy following upfront enucleation and diagnosis of HRHF. Variation exists worldwide among centers when defining HRHF, resulting in adverse patient outcomes, warranting standardization.

HIGH-RISK INTRAOCULAR RETINOBLASTOMA: Comparison Between Asian Indians and Americans From Two Major Referral Centers

PURPOSE

To identify the differences in the clinical and histopathologic features in eyes with advanced intraocular retinoblastoma in a developing country (India) versus a developed country (USA).

METHODS

Retrospective study.

RESULTS

Of 524 patients with retinoblastoma who underwent primary enucleation, 331 were from India, and 193 were from the USA. Asian Indians were older at presentation (35 months vs. 29 months; P = 0.02), had thicker tumors (13.8 mm vs. 12.4 mm; P = 0.0001) compared with Americans. High-risk intraocular retinoblastoma was more common in Asian Indians with a 2-fold greater risk compared with Americans (35% vs. 23%; odds ratio = 1.83; P = 0.003). Statistically significant differences in the histopathologic features (Asian Indians vs. Americans) included massive (≥3 mm) choroidal infiltration (17% vs. 6%; P = 0.0003) and optic nerve infiltration (48% vs. 15%; P = 0.0001). Asian Indians had a 5-fold greater risk of having optic nerve invasion (odds ratio = 5.45; P < 0.0001) and 3-fold greater risk of massive choroidal invasion (odds ratio = 2.80; P < 0.0001) compared with Americans. With appropriate use of adjuvant systemic chemotherapy, the difference in the rates of systemic metastasis (5% vs. 2%, P = 0.67) and related death in both countries (5% vs. 0%, P = 0.14) were not statistically significant.

CONCLUSION

High-risk intraocular retinoblastoma is more common in Asian Indians compared with Americans.

A multidisciplinary approach to improving the care and outcomes of patients with retinoblastoma at a pediatric cancer hospital in Egypt

BACKGROUND

Retinoblastoma poses a substantial burden in developing countries. We conducted this study to assess the effect of implementing a multidisciplinary approach and standardized protocols for treating pediatric patients with retinoblastoma at the Children's Cancer Hospital Egypt (CCHE).

MATERIALS AND METHODS

In January 2011, the CCHE implemented standardized protocols for the diagnosis, treatment, and reporting of retinoblastoma cases. The hospital also introduced a new retinoblastoma management algorithm and data analysis system. In this study, we compared the pathologic features, tumor invasiveness, reporting, and survival of 276 pediatric patients who underwent enucleations of 290 eyes before or after the implementation of the retinoblastoma protocols.

RESULTS

Time to enucleation (indicating time needed for decision taking) decreased significantly within the neoadjuvant chemotherapy group for intraocular disease after January 2011 (68.7 ± 48 weeks vs. 47.3 ± 28.3 weeks; p < 0.05). Mean optic nerve stump length increased from 5.6 mm in the earlier period to 7.2 mm in the later period (p = 0.004). The overall quality of pathology reporting also improved during the later period. The probability of 3-year survival was significantly higher for patients during the later period (94.2% vs. 79.2%; p = 0.018).

CONCLUSIONS

The implementation of standardized protocols and a multidisciplinary approach improved reporting; discrepancies in disease classification and the amount of missing data were reduced; and quality measures and prognostic capabilities of the team were substantially improved. Such established data-driven practice supports faster decision making to enucleate diseased eyes and save patients' lives through providing measurable indicators.

Retinoblastoma in Jordan, 2003-2013: ocular survival and associated factors

PURPOSE

To determine ocular survival and factors affecting globe survival in patients diagnosed with retinoblastoma at King Hussein Cancer Center (KHCC).

METHODS

A retrospective review of medical records of 71 Jordanian patients (45 males and 26 females) diagnosed with retinoblastoma (114 eyes) between June 2003 and May 2013 was conducted. Patient sociodemographic and relevant characteristics were collected from records. Patients with bilateral retinoblastoma were treated with chemoreduction and focal consolidation. Lens-sparing radiation therapy and enucleation were reserved for eyes that failed chemoreduction combined with focal therapy. In cases of unilateral retinoblastoma, primary enucleation was recommended for eyes with advanced unilateral disease (Reese-Ellsworth classification groups IV and V). Kaplan-Meier survival and Cox regression multilevel analysis were used to analyze the data.

RESULTS

Median age at diagnosis was 12 months. The follow-up period ranged from 0.25-160 months (mean 26.9 months). The Kaplan-Meier estimate of globe survival of the 114 eyes was 68.0% at 1 year, 63.3% at 2 years, and 62.1% at 5 years. The mean survival time was 101.6 months (95% confidence interval, CI, 87.6-115.6 months). In multivariable-adjusted analysis, advanced stage of the disease (hazard ratio, HR, 5.1, 95% CI 2.3-11.6), unilateral disease (HR 3.3, 95% CI 1.4-8.1), and delay in diagnosis (HR 2.4, 95% CI 1.1-5.5) were significantly associated with increased hazard of enucleation.

CONCLUSION

The overall ocular survival rate for eyes with retinoblastoma was close to regional and international figures. Disease stage, laterality, and delay in diagnosis were significant predictors of enucleation.

Survey on the management of orbital and intraocular tumors among oculofacial surgeons in the Asia-Pacific region

A web-based anonymous survey was performed to assess the common practices of oculofacial surgeons in the management of orbital and intraocular tumors in the Asia-Pacific region. The questionnaire comprised a series of questions covering controversial topics sent via email to 131 oculofacial surgeons across 14 countries in the Asia-Pacific region. A total response rate of 61.7 % was achieved from May to December 2012. The most common benign orbital tumor was cavernous hemangioma (39.6 %) and the most common malignant orbital tumor was lymphoma (85.7 %). 40 % of surgeons recommended orbital radiation, for which the most common indications were thyroid eye disease (70.0 %) and malignancy (30.0 %). The most common orbitotomy approach was lateral (79.2 %). Most surgeons (87.1 %) offered enucleation for retinoblastoma, but there was also a significant proportion that offered chemoreduction with transpupillary thermotherapy or cryotherapy (58.1 %). Fewer surgeons offered brachytherapy (16.1 %) and intra-arterial chemotherapy (6.5 %). When performing enucleation for retinoblastoma, 81.8 % of surgeons performed a primary orbital implant placement. The most preferred type of implant was silicone/acrylic (90.2, 90.2 and 87.8 % for elderly, adults and children, respectively). The majority of surgeons used donor sclera (57.5 %) or no wrapping material at all (32.5 %). Almost all surgeons (95.1 %) did not drill and peg the implant for motility. We report the results of the first survey of oculofacial surgeons in the Asia-Pacific region on the management of intraocular and orbital tumors. In comparison with previous surveys performed in the USA and the UK, we found the practice patterns of the Asia-Pacific surgeons to be comparable.

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.

Improved care of rhabdomyosarcoma in Jordan using less intensive therapy

BACKGROUND

The care of rhabdomyosarcoma (RMS) is complex due to its multimodal nature. By following standard protocols with acceptable toxicity and building local expertise, better outcome should be achievable.

PROCEDURE

A retrospective study was conducted of records of patients (n = 45; 31 males; median age 26 months) with RMS treated at King Hussein Cancer Center in Jordan from January 2004 to December 2008. Patient demographics, tumor characteristics, risk stratification, treatment plan, and outcomes were studied. In June 2006, the cyclophosphamide dose was lowered from 2.2 g/m(2) to 1.2 g/m(2) per cycle because of the significant toxicity with higher dose. Survival rates, hematological toxicities, period of hospitalization due to febrile neutropenia (FN), and response rate at week 12 of treatment were compared between low- and high-dose cyclophosphamide groups.

RESULTS

Four-year progression-free survival (PFS) and overall survival (OS) rates were 61% ± 7.5% and 72% ± 6.9%, respectively. There was a significant difference in outcome by risk group in 4-year PFS (low-risk, 88% ± 12%; intermediate-risk 63% ± 9.3%; high-risk, 14% ± 13%; P = 0.0001) and OS (low-risk, 88% ± 12%; intermediate-risk 79% ± 7.5%; high-risk, 17% ± 15%; P = 0.0011). There was significant reduction in hematological toxicities, incidence of FN, and period of hospitalization for FN in patients given low-dose cyclophosphamide but no significant difference in PFS between low- and high-dose cyclophosphamide groups.

CONCLUSIONS

Survival rates of patients with RMS in some developing countries can be improved by following or modifying evidence-based approaches successful in developed countries and establishing multidisciplinary strategies. Therapy intensity should be increased in developing countries only when evidence supports its utility.