Retinoblastoma with micrometastasis to CSF

Retinoblastoma with Cerebrospinal Fluid Metastasis Treated with Orbital and Craniospinal Irradiation Using IMRT

A 4-year-old male child presented with history of leucocoria, photophobia, and progressive visual deterioration in the left eye. Clinical examination and computed tomography revealed a unilateral retinoblastoma involving the left globe. He underwent enucleation of the left eye and was referred for adjuvant radiotherapy in view of optic nerve infiltration up to the line of resection. However, he did not report for treatment and presented six months later with a recurrent mass in the left orbit with intracranial extension. Cerebrospinal fluid (CSF) cytology was positive for malignant retinoblastoma cells. He received multiagent chemotherapy with vincristine, carboplatin, and etoposide along with intrathecal methotrexate. Although the recurrent orbital mass reduced significantly with chemotherapy, malignant cells persisted in the CSF. He was subsequently treated using intensity modulated radiation therapy (IMRT) to treat the left orbital mass along with craniospinal axis irradiation. Computed tomography done at three and nine months after completion of radiotherapy showed complete disappearance of orbital tumor. CSF cytology also showed no evidence of malignant cells.

Classification and management of seeds in retinoblastoma. Ellsworth Lecture Ghent August 24th 2013

Retinoblastoma has the unique capacity to accelerate its own intra-ocular propagation by adopting semi-solid or even liquid growth properties through seeding. Until recently, the presence of any degree of seeding was mostly incompatible with successful conservative management, due to the multiresistant nature of the seeds. Surprisingly, this well-recognized retinoblastoma behavior has not undergone any detailed description of seeding patterns and anatomic sites. In this paper, we describe the phenotypic variability of seeds across the four possible intraocular seeding compartments and classify them into three fundamental types: namely dust, spheres, and clouds. We also provide an overview of the different therapeutic strategies developed for seeding, with special attention to intravitreal chemotherapy as the treatment of choice for vitreous and retro-hyaloid seeding. Finally, we propose criteria to enable assessment of the response to treatment by reporting seed regression patterns, as well as a clinical grading system for the retinal toxicity observed following intravitreal melphalan.

Questioning the need for routine bone marrow aspiration and lumbar puncture in patients with retinoblastoma

PURPOSE

This study assesses the value of routinely investigating children with retinoblastoma with bone marrow aspiration and lumbar puncture, staging investigations not without risk and trauma to the patient, emotional stress on parents and financial cost to the community.

METHODS

Medical files and specimens were obtained and examined for patients with retinoblastoma presenting to the Royal Alexandra Hospital for Children, Camperdown and the Children's Hospital at Westmead, Sydney, from 1975 to 2001.

RESULTS

In total, 123 patients presented; 62 (50.4%) were boys and 61 (49.6%) were girls. Of these 123 patients, 74 (60.2%) had unilateral disease, 46 (37.4%) involving the left eye and 28 (22.8%) involving the right eye. There were 47 (38.2%) patients with bilateral disease, and two (1.6%) with trilateral disease. Mean age of presentation was 17.9 months (23.1 months for unilateral subjects; 10.3 months for bi-lateral subjects; 3.5 months for trilateral subjects). There were 13 (10.6%) with a positive family history. Of 74 unilateral subjects, 70 (94.6%) required enucleation and four (5.4%) were salvaged. Of 47 bilateral subjects, 13 (27.7%) did not require enucleation, 27 (57.4%) required unilateral enucleation and seven (14.9%) required bilateral enucleation. Both trilateral subjects died. Of all 123 subjects, 112 (91.1%) had bone marrow aspiration and lumbar puncture performed during initial assessment, and none showed evidence of malignancy.

CONCLUSIONS

Given the small but significant risks associated with these procedures, the results of this study cannot support bone marrow aspiration and lumbar puncture as routine investigations in all patients presenting with retinoblastoma, suggesting a more limited usage of these investigations is warranted.