At what age could screening for familial retinoblastoma be stopped? A register based study 1945-98

At What Age Could Screening for Familial Retinoblastoma Be Discontinued? A Systematic Review

The aim of this systematic review is to assess the latest age at diagnosis for detection of familial retinoblastoma in order to evaluate at what age screening of at-risk children could be discontinued. Extended screening beyond this age would result in unnecessary patient burden and costs. However, discontinuing screening prematurely would have the adverse effect of missing tumors. We performed a literature search (PubMed, Embase, CINAHL and the Cochrane Library) up until February of 2021 and systematically included studies where patients had a family history of retinoblastoma, a known age at diagnosis, and who were ophthalmologically screened for retinoblastoma from birth. A total of 176 familial retinoblastoma patients from 17 studies were included in this review. Based on 48 months of age being the latest age of diagnosis, ophthalmological screening for familial retinoblastoma could safely be discontinued at age four years.

ROUTINE FUNDUS SCREENING OF FAMILIES OF CHILDREN WITH RETINOBLASTOMA: A Prospective Study of 131 Consecutive Families

PURPOSE

To discuss the importance of routine ophthalmic examination of parents and siblings of retinoblastoma (RB) patients.

METHODS

Prospective nonrandomized observational/interventional case series of consecutive families of 131 RB patients.

RESULTS

Routine ophthalmic examination of families (parents and siblings) of 131 consecutive newly diagnosed RB patients, including 262 parents and 23 siblings, revealed spontaneously regressed RB in at least 1 parent of 10 (8%) patients and active RB in at least 1 sibling of 3 (2%) patients. Of the 10 parents with spontaneously regressed RB, the lesions were unilateral (n = 7) or bilateral (n = 3). The regression patterns (n = 13) were comparable with postirradiation regression patterns Type 1 (n = 3), Type 2 (n = 2), Type 3 (n = 2), and Type 4 (n = 3), and spontaneous phthisis bulbi (n = 3). Fundus screening of siblings revealed active RB in at least 1 sibling of 3 (2%) patients. Of these 3 siblings, 2 had unilateral and 1 had bilateral disease. The mean age at detection of RB was 15 months (median, 6 months; range, 2-36 months). The disease was unilateral in 2 and bilateral in 1 patient. Based on International Classification of Intraocular Retinoblastoma, the tumors (n = 4) were classified as Group A (n = 2) and Group B (n = 2).

CONCLUSION

Routine fundus screening of siblings allows for early detection of RB in otherwise asymptomatic children. Detection of spontaneously regressed RB in parents may act as a surrogate marker for germline RB1 mutation and is helpful in genetic counseling.

Retinoblastoma in older patients: A retrospective comparative analysis of 100 consecutive patients based on age

Purpose

To describe comparative clinical features, treatment, and outcomes of retinoblastoma in patients initially diagnosed at age 4 or older.

Methods

Retrospective case series.

Results

There were 101 eyes in 100 consecutive patients age ≥4 years diagnosed with retinoblastoma. Mean patient age at diagnosis was 6.6 years (median 5.3, range 4.0–41.0 years). Tumors were predominantly classified (International Classification of Retinoblastoma) as group D (31%) or E (65%). Patients were divided by age into 3 groups: young (4–6 years [65%]), middle (>6–8 years [23%]), and older (>8 years [12%]). Comparing by age group (young vs. middle vs. older), mean tumor basal diameter (19.9 vs. 17.3 vs. 17.0 mm, p = 0.05) and mean tumor thickness (11.0 vs. 9.4 vs. 7.0 mm, p < 0.01) were greatest in the youngest group. Distance to the optic nerve (1.5 vs. 1.7 vs. 5.0 mm, p = 0.01) and foveola (1.9 vs. 1.8 vs. 6.0 mm, p < 0.01) were greatest in the oldest age group. Objective findings of leukocoria and strabismus were more common in younger patients, while older patients complained of subjective findings, like decreased vision (19% vs. 30% vs. 60%, p < 0.01) and floaters (3% vs. 4% vs. 17%, p = 0.05). Primary treatment included enucleation (76%) and other modalities (24%). Globe salvage rate was 13%, with no significant difference by age. Comparison of globe salvage by revealed significant improvement between 1974–2008 (6%) and 2009–2017 (38%, p < 0.01).

Conclusion

Retinoblastoma in older patients (>8 years) tends to be smaller and more peripherally located, with more subjective presenting symptoms.

Retinoblastoma and Neuroblastoma Predisposition and Surveillance

Retinoblastoma (RB) is the most common intraocular malignancy in childhood. Approximately 40% of retinoblastomas are hereditary and due to germline mutations in the RB1 gene. Children with hereditary RB are also at risk for developing a midline intracranial tumor, most commonly pineoblastoma. We recommend intensive ocular screening for patients with germline RB1 mutations for retinoblastoma as well as neuroimaging for pineoblastoma surveillance. There is an approximately 20% risk of developing second primary cancers among individuals with hereditary RB, higher among those who received radiotherapy for their primary RB tumors. However, there is not yet a clear consensus on what, if any, screening protocol would be most appropriate and effective. Neuroblastoma (NB), an embryonal tumor of the sympathetic nervous system, accounts for 15% of pediatric cancer deaths. Prior studies suggest that about 2% of patients with NB have an underlying genetic predisposition that may have contributed to the development of NB. Germline mutations in ALK and PHOX2B account for most familial NB cases. However, other cancer predisposition syndromes, such as Li-Fraumeni syndrome, RASopathies, and others, may be associated with an increased risk for NB. No established protocols for NB surveillance currently exist. Here, we describe consensus recommendations on hereditary RB and NB from the AACR Childhood Cancer Predisposition Workshop. Clin Cancer Res; 23(13); e98-e106. ©2017 AACRSee all articles in the online-only CCR Pediatric Oncology Series.

Screening Children at Risk for Retinoblastoma: Consensus Report from the American Association of Ophthalmic Oncologists and Pathologists

PURPOSE

To provide a set of surveillance guidelines for children at risk for development of retinoblastoma.

DESIGN

Consensus panel.

PARTICIPANTS

Expert panel of ophthalmic oncologists, pathologists, and geneticists.

METHODS

A group of members of the American Association of Ophthalmic Oncologists and Pathologists (AAOOP) with support of the American Association for Pediatric Ophthalmology and Strabismus and the American Academy of Pediatrics (AAP) was convened. The panel included representative ophthalmic oncologists, pathologists, and geneticists from retinoblastoma referral centers located in various geographic regions who met and discussed screening approaches for retinoblastoma. A patient "at risk" was defined as a person with a family history of retinoblastoma in a parent, sibling, or first- or second-degree relative.

MAIN OUTCOME MEASURES

Screening recommendations for children at risk for retinoblastoma.

RESULTS

Consensus statement from the panel: (1) Dedicated ophthalmic screening is recommended for all children at risk for retinoblastoma above the population risk. (2) Frequency of examinations is adjusted on the basis of expected risk for RB1 mutation. (3) Genetic counseling and testing clarify the risk for retinoblastoma in children with a family history of the disease. (4) Examination schedules are stratified on the basis of high-, intermediate-, and low-risk children. (5) Children at high risk for retinoblastoma require more frequent screening, which may preferentially be examinations under anesthesia.

CONCLUSIONS

Risk stratification including genetic testing and counseling serves as the basis for screening of children at elevated risk for development of retinoblastoma.

Consideraciones clínicas, diagnósticas y de tratamiento en retinoblastoma

El  retinoblastoma es el  tumor  intraocular  primario más frecuente en la infancia. Su detección temprana y el inicio del tratamiento adecuado permiten mejorar  dramáticamente la sobrevida en estos niños. En este artículo se hace una revisión general de la enfermedad. Se empleó PubMed y se revisaron artículos representativos del tema, que permitieran dar una idea general de los diferentes avances alcanzados. Dada su clínica característica, el médico de atención primaria, es pieza fundamental en la captación inicial del paciente.

Reproductive behavior of individuals with increased risk of having a child with retinoblastoma

To investigate reproductive behavior of individuals at increased risk of having a child with retinoblastoma (Rb), we conducted a cross-sectional questionnaire survey among 118 counselees visiting the Clinical Genetics Department of the National Rb Center in the Netherlands. The recurrence risk for counselees ranged from <1% to 50%. The response rate was 69%. Of 43 respondents considering having children after becoming aware of their increased risk, Rb influenced reproductive behavior for 25 (58%), of whom 14 had a recurrence risk <3%. Twenty of these 25 decided against having more children and 5 used prenatal diagnosis. Eighteen of the 43 respondents did not use any of the alternative reproductive options and had children (or more children), although half indicated having had doubts about their decisions. Multiple logistic regression showed that only perceived risk (p = 0.003) was significantly associated with Rb influencing reproductive behavior. Of 17 respondents planning children (or more children), 11 (65%) considered using one of the alternative reproductive options. We conclude that reproductive behavior is greatly influenced by Rb and that perceived risk, not objective risk, is the most important factor of influence. It is important to offer individuals at increased risk continued access to genetic counseling, even when this risk is small.

Familial retinoblastoma: fundus screening schedule impact and guideline proposal. A retrospective study

AIMS

To assess if systematic fundus screening according to an 'intensive' schedule alters ocular outcome and to propose fundus screening schedule guidelines for children related to a retinoblastoma patient.

METHODS

For children with a positive family history of retinoblastoma, we perform fundus exams shortly after birth under general anaesthesia and then at regular intervals according to schedules based on the risk. Familial retinoblastoma cases seen at our institution from January 1995 to December 2004 were retrospectively classified as 'screened' or 'non-screened' (NS) and, among the 'screened' patients, as 'intensively screened' (IS) if screening matched our recommendations or 'non-intensively screened' (S). Groups were compared by Fisher exact test for categorical variables and Kruskal-Wallis test for continuous variables.

RESULTS

Among the 547 retinoblastoma patients managed at our institution during this period, 59 were familial cases. In all, 20 were in the NS group, 23 in the S group, and 16 in the IS group. The number of children enucleated was, respectively, 13, 2, and 0 (P<10(-4)); external beam radiation (EBRT) was required for, respectively, 6, 0, and 2 children (P<0.009). Chemotherapy burden and visual acuity were not significantly different between groups.

CONCLUSION

An 'intensive' fundus screening schedule decreased the need for enucleation and EBRT. Therefore, despite the heavy burden of the screening schedule, we recommend physicians and health-care professionals to better inform and refer children with a family history of retinoblastoma for genetic counselling and proper fundus screening in specialized centres.

Role of genetic testing in retinoblastoma management at a tertiary referral centre

BACKGROUND

Retinoblastoma (MIM +180 200) is a malignant neoplasm affecting embryonal retina, associated with mutations in the RB1 gene. This paper investigates the results of RB1 testing in retinoblastoma management in a tertiary referral centre.

METHODS

A retrospective audit of genetic testing for retinoblastoma from 2003 to 2008, to determine epidemiology, rate of mutation detection and spectrum was undertaken. Eligible probands were identified from the department database and hospital records examined. DNA extracted from tumour tissue and/or peripheral blood was analysed. All patients and families underwent genetic counselling.

RESULTS

Twenty patients, including one family, were identified. Eight had bilateral tumours, of whom seven presented before 2 years of age, whereas 10 of 12 unilateral cases presented after 2 years of age. Ten patients (50%) were European, four Maori (20%), three Pacific (15%), two Asian (10%), and one of mixed ancestry (5%). Genetic analysis achieved mutation detection on all affected alleles of all the patients, with tumour tissue available for testing in 19 cases. Ten (40%) had germline mutations (eight bilateral and two unilateral), including one mosaic. 75% of affected Maori had germline mutations compared with 40% Europeans. A wide range of mutations was detected with one novel mutation identified in a familial case.

CONCLUSION

Advances in gene testing have enabled a high rate of mutation detection, particularly when tumour tissue is genotyped. Genetic analysis is integral to the management of retinoblastoma patients allowing enhanced follow-up care, avoidance of unnecessary examinations, family screening, counselling and reproductive planning, with early tumour detection in predisposed individuals.

Genetic testing and tumor surveillance for children with cancer predisposition syndromes

PURPOSE OF REVIEW

Genetic testing for the presence of germline mutations in cancer-predisposing genes can identify individuals at increased cancer risk. For these individuals, the institution of cancer surveillance measures is recommended with the aim of detecting cancers at early and hence more curable stages. While these principles are well established in adults, they are only entering the pediatric arena.

RECENT FINDINGS

The care of children with cancer-predisposing conditions remains a challenge for the practicing clinician. Here, we describe recent findings related to genetic testing and cancer surveillance in three conditions marked by the development of tumors during childhood, including retinoblastoma, Beckwith-Wiedemann syndrome/idiopathic hemihypertrophy and the Wilms' tumor-associated syndromes. We use these conditions to demonstrate how the integration of clinical genetic testing and cancer monitoring has favorably influenced the survival and quality of life for patients. Where possible, we provide evidence-based guidelines for patient management.

SUMMARY

Advances in the understanding of cancer predisposition and implementation of standardized cancer surveillance protocols have improved the outcome for certain patients. Future research focusing on enhancing the sensitivity of genetic testing and efficacy of surveillance for at-risk populations could further decrease the morbidity and mortality associated with these conditions.

Shorter time to diagnosis and improved stage at presentation in Swiss patients with retinoblastoma treated from 1963 to 2004

OBJECTIVES

Retinoblastoma is the most frequent intraocular malignancy in children. Early diagnosis is essential for globe salvage and patient survival. The aim of our study was to determine how time to diagnosis of retinoblastoma has evolved over a 40-year period in Switzerland.

METHOD AND PATIENTS

A retrospective study of 139 Swiss patients with retinoblastoma was performed comparing 3 periods: (1) 1963-1983; (2) 1984-1993; and (3) 1994-2004. Factors taken into account were gender, laterality of retinoblastoma, age at first symptoms, type and first observer of symptoms, time to diagnosis, age at diagnosis, disease stage, and family history.

RESULTS

Thirty-seven patients (26.6%) were treated in period 1, 44 (31.7%) in period 2, and 58 (41.7%) in period 3. Overall, the diagnostic interval decreased in a significant way from 6.97 months in period 1 to 3.58 in period 2 and to 2.25 in period 3. When looking separately at unilateral and bilateral disease, the decrease of the diagnostic interval remained statistically significant in unilateral retinoblastoma; there was also a significant reduction in the number of patients with advanced group E disease (Murphree classification) (61.5% in period 1, 46.7% in period 2, 22.2% in period 3). In bilateral disease, the same observations were made to a lesser extent. However, there were no cases with group E disease in 10 patients with positive family history. Leukocoria (48.2%) and strabismus (20.1%) were the 2 most frequent symptoms throughout the 3 periods. The only factors that statistically influenced the chances of having a diagnosis of group E disease were the diagnostic interval and period of diagnosis.

CONCLUSIONS

Progress has been made in the diagnosis of retinoblastoma in Switzerland, notably in unilateral disease. Improvement to a lesser extent has also been observed in bilateral cases but without statistical significance. Greater effort is needed to teach physicians-in-training to recognize the importance of ocular symptoms and refer patients earlier.

Stage of presentation and visual outcome of patients screened for familial retinoblastoma: nationwide registration in the Netherlands

BACKGROUND

In the Netherlands a comprehensive programme for screening just after birth for familial retinoblastoma is taking place. In this report the stage of the disease at the time of detection, by way of screening, and the long term visual outcome in these patients was evaluated.

METHODS

A nationwide, retrospective study. From January 1992-July 2004, patients at risk for familial retinoblastoma were screened 1-2 weeks after birth, and investigated for laterality, Reese-Ellsworth classification/International Classification of Retinoblastoma, macular involvement, age of primary retinoblastoma, initial therapy, and visual outcome.

RESULTS

17 patients were diagnosed with familial retinoblastoma. 88.3% developed bilateral, 11.7% unilateral retinoblastoma. Of the 34 eyes, 56% were R-E group I, 16% were group II A-B, 16% were group III A-B, 9% were group IV, 3% were group V. Using the International Classification of Retinoblastoma, 72% were group A, 19% were group B, 6% were group C, 3% were group E. The visual outcome revealed 73.5% of eyes with 20/20-20/40, 26.5% eyes with < or = 20/100-no light perception; 5.9% of eyes were enucleated, all other eyes were treated with local or conservative treatment methods. Of all eyes, 59% had extramacular retinoblastoma, 98% of patients had at least one eye with extramacular retinoblastoma.

CONCLUSION

Most familial retinoblastoma patients present as a R-E group I or group A when screened within 2 weeks after birth. Nearly 90% of patients had a long term visual acuity of 20/20-20/40. Despite the common occurrence of macula involvement, bilateral macula involvement was infrequent, and since most eyes were salvaged, good vision was obtained in the majority of patients.

Lack of efficacy of dilated screening for retinoblastoma

PURPOSE

To assess red reflex testing of the pharmacologically dilated pupil in screening for retinoblastoma.

PATIENTS AND METHODS

Children with a family history of retinoblastoma or a history of treated retinoblastoma who were admitted to our institution for examination using anesthesia during a 3-month period underwent red reflex testing of the pharmacologically dilated pupil in a masked fashion. Red reflexes were classified as normal (unremarkable), abnormal (in brightness or color), or absent (no reflex, black pupil). The results of the screenings were later compared with actual retinal findings.

RESULTS

Red reflex testing of the dilated pupil failed to identify all 13 eyes that harbored retinoblastoma lesions (all 13 were classified as normal). The 3 eyes that were identified as having abnormal red reflexes had neither disease nor significant refractive error.

CONCLUSION

Red reflex testing of the dilated pupil is a poor screening technique for retinoblastoma.

New retinoblastoma tumor formation in children initially treated with systemic carboplatin

PURPOSE

To determine the frequency and timing of new intraocular tumor formation in children with hereditary retinoblastoma initially treated with systemic carboplatin.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

This study included 34 children (57 eyes) with hereditary bilateral retinoblastoma initially treated with systemic carboplatin at the Robert M. Ellsworth Ophthalmic Oncology Center at NewYork-Presbyterian Hospital from 1994 through 2000.

MAIN OUTCOME MEASURES

New tumor formation after initial treatment with systemic carboplatin.

RESULTS

There were a total of 165 tumors in 57 eyes. There were 63 new tumors in 27 eyes (47%) after administration of systemic carboplatin, for a mean of 1.1 new tumors per eye. The mean patient age at time of new tumor presentation was 9 months, with 57% of new tumors developing within 4 months of carboplatin treatment. Kaplan-Meier analysis showed that children who were treated when younger than 6 months of age were more likely to have new tumors (60%) compared with those treated after 6 months of age (31%; P = 0.0182).

CONCLUSIONS

New intraocular tumors continue to develop after systemic carboplatin; most new tumors appeared within 4 months of treatment.

Genetic predisposition and screening in pediatric cancer

Pediatricians are often the health care providers who first detect the signs and symptoms of childhood cancer. Although pediatric malignancies are rare diseases, early diagnosis is an important factor leading to high cure rates of many types of cancers including retinoblastomara, Wilms' tumor, hepatoblastoma, rhabdomyosarcoma. thyroid carcinoma, and other solid tumors. A number of familial cancer syndromes present with childhood cancers that can be recognized or diagnosed by pediatricians. The genetic origins of several syndromes have been elucidated. Genetic testing is not yet available for all of these inherited cancers. A frequently updated list of genetic tests is available at www.genetests.org. The ordering and interpreting of genetic tests, however, is often best done by trained genetic counselors. The pediatrician will play a vital on-going role in following the at-risk child. In many of syndromes discussed, the cost effectiveness of the tests as well as that of any potential intervention needs further study. The role of the subtle genetic polymorphisms in pediatric tumorigenesis. many more of which will undoubtedly be described in the coming years, has not yet been translated into defined needs for interventions. Perhaps in the future it will be possible to understand the additive effect of multiple genetic polymorphisms and to determine genetic profiles of high cancer risk. Until suitable interventions are established, however, the study of genetic variability and cancer will await practical significance. Undoubtedly other major important cancer genes are yet to be discovered and characterized. An additional challenge is the counseling and management of children and adults who have a strong family history of cancer yet who do not have a recognizable syndrome. The role of the primary pediatrician is to recognize the major cancer genetic syndromes, to make appropriate referrals for genetic counseling and testing when indicated, and to ensure that adequate screening tests are being done.