The Role of Intraarterial Chemotherapy in the Management of Retinoblastoma

Joint CB1 and NGF Receptor Activation Suppresses TRPM8 Activation in Etoposide-Resistant Retinoblastoma Cells

In childhood, retinoblastoma (RB) is the most common primary tumor in the eye. Long term therapeutic management with etoposide of this life-threatening condition may have diminishing effectiveness since RB cells can develop cytostatic resistance to this drug. To determine whether changes in receptor-mediated control of Ca2+ signaling are associated with resistance development, fluorescence calcium imaging, semi-quantitative RT-qPCR analyses, and trypan blue dye exclusion staining patterns are compared in WERI-ETOR (etoposide-insensitive) and WERI-Rb1 (etoposide-sensitive) cells. The cannabinoid receptor agonist 1 (CNR1) WIN55,212-2 (40 µM), or the transient receptor potential melastatin 8 (TRPM8) agonist icilin (40 µM) elicit similar large Ca2+ transients in both cell line types. On the other hand, NGF (100 ng/mL) induces larger rises in WERI-ETOR cells than in WERI-Rb1 cells, and its lethality is larger in WERI-Rb1 cells than in WERI-ETOR cells. NGF and WIN55,212-2 induced additive Ca2+ transients in both cell types. However, following pretreatment with both NGF and WIN55,212-2, TRPM8 gene expression declines and icilin-induced Ca2+ transients are completely blocked only in WERI-ETOR cells. Furthermore, CNR1 gene expression levels are larger in WERI-ETOR cells than those in WERI-Rb1 cells. Therefore, the development of etoposide insensitivity may be associated with rises in CNR1 gene expression, which in turn suppress TRPM8 gene expression through crosstalk.

Urinary bladder retention secondary to intranasal administration of oxymetazoline "Afrin" for intra-arterial chemotherapy

Selective ophthalmic artery infusion of chemotherapy (SOAIC) has emerged as the standard of care for retinoblastoma (RB). Intranasal oxymetazoline (INO), Afrin, is often intraoperatively administered adjunctively to optimize flow to the orbit. There has been one report to date that suggests the adjunctive use of INO has led to systemic side effects. To our knowledge, this is the first documented case of INO causing urinary retention in a patient undergoing SOAIC, and the recommended treatment.

Comparing internal versus external carotid artery branch delivery of intraarterial chemotherapy for the treatment of retinoblastoma

PURPOSE

The goal of this study was to compare the efficacy of intraarterial chemotherapy (IAC) for retinoblastoma delivered via the ophthalmic artery (OA) division of the internal carotid artery (ICA) versus alternative branches of the external carotid artery (ECA).

METHODS

We performed a retrospective chart review of patients receiving IAC for retinoblastoma at a single institution. Subjects were divided into three groups: those that received IAC solely through the OA branch of the ICA, those that initially received IAC through the OA branch of the ICA but were later switched to the ECA, and those that only received IAC through the ECA. The main outcomes compared included globe salvage rate and reduction in tumor thickness and size.

RESULTS

A total of 30 eyes from 26 patients were included. A total of 91 (58%) sessions of IAC were performed through the OA division of the ICA and 65 (42%) were performed through branches of the ECA. Eleven eyes (37%) solely received IAC through the OA branch of the ICA, 16 eyes (53%) were converted to ECA treatment, and 3 eyes solely received IAC through branches of the ECA. Statistical analysis did not show any significant difference in globe salvage rate or reduction in tumor thickness and size.

CONCLUSION

The use of alternative approaches for IAC when the OA branch of the ICA catheterization is not feasible allows for safe continued delivery of highly effective IAC, leading to similar outcomes in terms of globe salvage and reduction in tumor size.

Evolving indications for pediatric neurointerventional radiology: A single institutional 25-year experience in infants less than one year of age and a brief historical review

BACKGROUND AND PURPOSE

Pediatric neurointerventional radiology is an evolving subspecialty with growing indications and technological advancement such as miniaturization of devices and decreased radiation dose. The ability to perform these procedures is continuously balanced with necessity given the inherently higher risks of radiation and cerebrovascular injury in infants. The purpose of this study is to review our institution's neurointerventional experience in infants less than one year of age to elucidate trends in this patient population.

METHODS

We retrospectively identified 132 patients from a neurointerventional database spanning 25 years (1997-2022) who underwent 226 procedures. Treatment type, indication, and location as well as patient demographics were extracted from the medical record.

RESULTS

Neurointerventional procedures were performed as early as day of life 0 in a patient with an arteriovenous shunting malformation. Average age of intervention in the first year of life is 5.9 months. Thirty-eight of 226 procedures were completed in neonates. Intra-arterial chemotherapy (IAC) for the treatment of retinoblastoma comprised 36% of neurointerventional procedures completed in infants less than one year of age followed by low flow vascular malformations (21.2%), vein of Galen malformations (11.5%), and dural arteriovenous fistulas (AVF) (9.3%). Less frequent indications include non-Galenic pial AVF (4.4%) and tumor embolization (3.0%). The total number of interventions has increased secondary to the onset of retinoblastoma treatment in 2010 at our institution.

CONCLUSION

The introduction of IAC for the treatment of retinoblastoma in the last decade is the primary driver for the increased trend in neurointerventional procedures completed in infants from 1997 to 2022.

The Efficacy of Alternate Systemic Intravenous Chemotherapy and Intra-arterial Chemotherapy Approach for Eye Globe Salvage in Retinoblastoma

PURPOSE

The advances in the treatment of retinoblastoma have enabled salvaging the globe in advanced stages with intra-arterial chemotherapy (IAC). We developed a strategy of alternate application of systemic intravenous chemotherapy (IVC) and IAC (referred to as alternate systemic IVC and IAC; ASIAC) to reduce central nervous metastases during IAC and examined its efficacy and safety in eye globe salvage in this study.

MATERIALS AND METHODS

Between January 2010 and February 2021, 43 eyes of 40 patients received ASIAC treatment for retinoblastoma at the Yonsei Cancer Center, Yonsei University Health System. Their medical records were reviewed retrospectively to evaluate the eye salvage rate (ESR), defined from diagnosis to enucleation. High-risk retinoblastoma was defined as group D or E by the International Classification of Retinoblastoma.

RESULTS

The study enrolled 38 and five cases of high-risk and low-risk retinoblastoma, respectively. In total, 178 IAC and 410 IVC courses were administered, with a median of 4 (interquartile range [IQR], 3.0 to 5.0) IAC and 9 (IQR, 6.0 to 11) IVC courses per eye, respectively. The 5-year ESR was 60.4%±8.7% for the whole cohort, 100% for low-risk retinoblastoma, and 53.6%±9.8% for high-risk retinoblastoma. Among those diagnosed since 2015, the 5-year ESR for high-risk retinoblastoma was 63.5%±14.0%. Fifteen eyes underwent enucleation; no viable tumor was found in three enucleated eyes. There were no deaths in this cohort.

CONCLUSION

Primary IAC-IVC (i.e., ASIAC) for patients with retinoblastoma was tolerable and effective in salvaging the eye and maintaining survival.

Osthole exhibits an antitumor effect in retinoblastoma through inhibiting the PI3K/AKT/mTOR pathway via regulating the hsa_circ_0007534/miR-214-3p axis

CONTEXT

Osthole shows antitumor effects in various tumours. Studies describing the effect of osthole on retinoblastoma (RB) are rare.

OBJECTIVE

This study investigates the antitumor activity of osthole on RB.

MATERIALS AND METHODS

RB cells were treated with different concentrations of osthole and then subjected to cell viability, colony formation, apoptosis, and western blot assays. The expression of hsa_circ_0007534 in RB tissues was determined by qRT-PCR. Hsa_circ_0007534 overexpression plasmid (oe-circ_0007534), miR-214-3p mimics and negative controls were transfected into RB cells to investigate cell viability. Athymic nude mice were injected with Y-79 cells to establish subcutaneous RB models. These mice were treated with osthole (0.5 mmol/kg) or corn oil for 36 days. Tumour tissues were collected for further analysis.

RESULTS

Osthole inhibited cell viability of RB cells with an IC₅₀ of 200 μM for 24 h treatment and 120 μM for 48 h treatment, respectively. Hsa_circ_0007534 was increased significantly in RB tissues as compared to the matched nontumor tissues (p < 0.001). Oe-circ_0007534 counteracted the inhibitory effect of osthole on cell viability and colony numbers of Y-79 cells (p < 0.01). In vivo experiments indicated osthole significantly decreased the expression of hsa_circ_0007534 (p < 0.01) and increased the level of miR-214-3p in vivo. Furthermore, as compared to the control, osthole decreased the ratios of p-PI3K/PI3K, p-AKT/AKT and p-mTOR/mTOR (p < 0.01). However, hsa_circ_0007534 overexpression reversed the effect of osthole on the PI3K/AKT/mTOR pathway.

DISCUSSION AND CONCLUSIONS

Osthole exhibited an antitumour effect in RB, providing a scientific basis for further research and clinical applications of osthole in RB treatment.

Long-Term Results after Intraocular Surgery in Treated Retinoblastoma Eyes

Introduction: The aim of the study was to analyze the results of intraocular surgery in treated retinoblastoma eyes and to assess the long-term results with a priority on local recurrences, secondary enucleation, and metastases. Methods: Retrospective noncomparative case series. Results: From March 1964 to January 2020, 42 eyes of 40 retinoblastoma patients underwent intraocular surgery. Time interval between the last therapy and surgery was 9.5 years (mean: 114 months; median: 54.5 months). 31 eyes were treated for radiogenic cataract formation with a gain in visual acuity of 61.3%. One child developed an upper eyelid metastasis, 3 showed second primary malignancies (SPM), one a late recurrence, and 2 eyes were enucleated. Retinal surgery was performed in 17 eyes; 6 eyes were done as a combined procedure. Indications were radiogenic complications in the sense of a vitreous hemorrhage in 11 eyes and a rhegmatogenous retinal detachment in 6 eyes. 41.2% of the treated eyes had a postoperative gain in visual acuity, whereas 9.5% of the eyes could not be preserved in the long term. Regarding systemic involvement 2 patients developed late recurrences and one a SPM. Conclusion: Surgical therapy in treated retinoblastoma is necessary in isolated cases. In our series, cataract surgery was a safe procedure with a good option of a significant increase in visual acuity. As expected, vitreoretinal treated eyes showed a limited gain in visual acuity, a higher risk of late recurrences, and a lower globe retention rate. Therefore, a careful indication and individual risk-benefit analysis are mandatory.

Intra-arterial chemotherapy for retinoblastoma: Our first experience in Indonesia

Intra-arterial chemotherapy (IAC) has become the mainstay therapy for retinoblastoma group D and E for the past few decades. However, IAC had never been done in Indonesia before. In this report, we present a case of a 2-year-old girl with recurrent Group D retinoblastoma of the left eye that improved significantly after one session of IAC, the first IAC in Indonesia.

Advances in biomaterials for the treatment of retinoblastoma

Retinoblastoma is the most common primary intraocular malignancy in children. Although traditional chemotherapy has shown some success in retinoblastoma management, there are several shortcomings to this approach, including inadequate pharmacokinetic parameters, multidrug resistance, low therapeutic efficiency, nonspecific targeting, and the need for adjuvant therapy, among others. The revolutionary developments in biomaterials for drug delivery have enabled breakthroughs in cancer management. Today, biomaterials are playing a crucial role in developing more efficacious retinoblastoma treatments. The key goal in the evolution of drug delivery biomaterials for retinoblastoma therapy is to resolve delivery-associated obstacles and lower nonlocal exposure while ameliorating certain adverse effects. In this review, we will first delve into the historical perspective of retinoblastoma with a focus on the classical treatments currently used in clinics to enhance patients' quality of life and survival rate. As we move along, we will discuss biomaterials for drug delivery applications. Various aspects of biomaterials for drug delivery will be dissected, including their features and recent advances. In accordance with the current advances in biomaterials, we will deliver a synopsis on the novel chemotherapeutic drug delivery strategies and evaluate these approaches to gain new insights into retinoblastoma treatment.

The role of m6A modification in pediatric cancer

With the development of RNA modification research, the importance of N6-methyladenosine (m6A) in tumors cannot be ignored. m6A promotes the self-renewal of tumor stem cells and the proliferation of tumor cells. It affects post-transcriptional gene expression through epigenetic mechanisms, combining various factors to determine proteins' fate and altering the biological function. This modification process runs through the entire tumors, and genes affected by m6A modification may be the critical targets for cancers breakthroughs. Though generally less dangerous than adult cancer, pediatric cancer accounts for a significant proportion of child deaths. What is more alarming is that the occurrences of adult tumors are highly associated with the poor prognoses of pediatric tumors. Therefore, it is necessary to pay attention to the importance of pediatric cancer and discover new therapeutic targets, which will help improve the therapeutic effect and prognoses of the diseases. We collected and investigated m6A modification in pediatric cancers based on mRNA and non-coding RNA, finding that m6A factors were involved in glioma, hepatoblastoma, nephroblastoma, neuroblastoma, osteosarcoma, medulloblastoma, retinoblastoma, and acute lymphoblastic leukemia. Consequently, we summarized the relationships between the m6A factors and these pediatric cancers.

Changes in Treatment Patterns and Globe Salvage Rate of Advanced Retinoblastoma in Korea: Efficacy of Intra-Arterial Chemotherapy

(1) Background: To analyze changes in treatment patterns for advanced retinoblastoma over time and differences in globe salvage rates; (2) Methods: Retrospective, observational case-control study of 97 eyes of 91 patients with advanced retinoblastoma (Group D and E).; (3) Results: Patients were divided into two groups based on whether they were treated before or after intraarterial chemotherapy (IAC) was introduced in our center in 2010. Before 2010, primary treatment pattern was enucleation, which was performed in 57.6% of cases, whereas primary treatment pattern after 2010 was IAC combined with intravenous chemotherapy (IVC), which was performed in 78.1%. Intravitreal chemotherapy (IVitC) has been performed to treat vitreous and subretinal seeding since 2015. The 5-year globe salvage rate of IVC alone was 24.0% for Group D and 0% for Group E, whereas that of IVC–IAC was 50.4% for Group D and 49.7% for Group E. Whether IVitC was performed or not did not significantly contribute to globe salvage rate. There was one metastatic death in the IVC alone group.; (4) Conclusions: Primary treatment pattern changed from enucleation to IAC-based treatment, which can now save nearly half of eyes with advanced retinoblastoma with excellent safety profile and survival rate.

Risk factors for chemotherapy-induced vomiting after general anesthesia in children with retinoblastoma: a retrospective study

BACKGROUND

The chemotherapy-induced vomiting (CIV) severely affects the daily function, nutritional status, treatment compliance, therapeutic efficacy, curability, and the quality of life of patients. The aim of this study was to find the risk factors for CIV after general anesthesia in patients with retinoblastoma (RB).

METHODS

A retrospective review of the hospital records of children with RB, who underwent chemotherapy between January 2017 and December 2019, was conducted at our hospital.

RESULTS

Data of a total of 803 children with RB were reviewed. The incidence of CIV in children with RB was 19.30%. Univariate analysis showed statistically significant differences in age, height, weight, chemotherapy regimen, anesthesia dose, duration of surgery and general anesthesia, platelet count, platelet distribution width, lymphocytes, and indirect bilirubin between patients with and without vomiting (P<0.05). Multivariate logistic regression analysis showed that the main predictors of CIV in children with RB included older age [odds ratio (OR), 1.32; 95% confidence interval (CI): 1.11-1.56; P<0.01], low platelet count (OR, 0.997; 95% CI: 0.995-0.999; P<0.05), and chemotherapy regimen (intravenous chemotherapy versus intra-arterial chemotherapy; OR, 0.47; 95% CI: 0.29-0.76; P<0.01).

CONCLUSIONS

This study revealed age, chemotherapy regimen, and platelet count as risk factors of CIV after general anesthesia in children with RB. Younger age and higher platelet count were protective factors for CIV. Compared with intravenous chemotherapy, the incidence of CIV was lower than that of intra-arterial chemotherapy. Although these factors cannot be modified, they can predict whether a patient may experience vomiting, assisting medical staff to formulate measures and intervenes in advance.

KEYWORDS

Retinoblastoma (RB); chemotherapy-induced vomiting (CIV); general anesthesia; multivariate analysis; risk factors.

Intraarterial Chemotherapy for Retinoblastoma - Initial Experiences of a German Reference Centre

BACKGROUND

Adequate management of retinoblastoma requires a multidisciplinary and individual approach to treatment. Intraarterial chemotherapy (IAC) is one of the most commonly used treatment modalities, and enables supraselective application of chemotherapy via the ophthalmic artery and is now established in almost all treatment centres. However, published treatment success rates are heterogeneous. There are some unanswered issues regarding sight-threatening ocular complications and the long-term occurrence of secondary malignancies and metastatic disease. The objective of the present study is to analyse the results of a German national reference centre.

METHODS

Retrospective analysis of all children with an indication for at least one IAC from April 2010 to April 2020. IAC was used either as primary or recurrence therapy. Obligatory follow-up was at least 6 months.

RESULTS

137 eyes of 127 children with an indication for IAC could be included. 12 eyes with a follow-up of less than 6 months and 37 eyes in which IAC was technically not feasible were excluded. In summary, 88 eyes of 79 children were finally analysed. Mean follow-up was 38 months, ranging from 7 to 117 months. In total, 195 procedures were completed. In 30 eyes (34.1%) IAC was conducted as primary and in 58 (65.9%) as secondary therapy. There was an initial IAC treatment response in 75 eyes (85.2%) with a recurrence-free rate of 61.3%. Eye salvage rate was 68.1% with 28 enucleated eyes in total. Ocular complications were observed in 36 eyes (40.9%), with 19 eyes (21.6%) showing severe sight-threatening and 11 eyes (12.5%) presenting minor non-sight-threatening toxic reactions. During follow-up, 1 child developed a secondary malignancy, 1 child developed metastasis and 1 child died as a consequence of trilateral retinoblastoma.

CONCLUSION

In summary, IAC is a potent modality for retinoblastoma treatment and has been very successful, even in advanced disease and heavily pretreated eyes. However, ocular complications should be taken in consideration, especially when the only seeing eye is treated. Long term incidences of secondary malignancies and metastatic diseases should be further investigated in prospective studies.

Retinoblastoma in Taiwan: survival and clinical characteristics

PURPOSE

To figure out the impact of national health insurance program and treatment modalities on the clinical outcomes of patients with retinoblastoma.

STUDY DESIGN

Retrospective cohort study.

METHODS

Enrolled patients were classified into three groups according to the time period in which their initial diagnosis was performed: patients diagnosed before 1995 (group 1), patients diagnosed in the time period 1995-2010 (group 2), patients diagnosed after 2010 (group 3). Comparison was made of clinical features including presenting signs, tumor spreading, and treatment modes. Survival and globe salvage rates were analyzed within each group.

RESULTS

There were 157 patients (202 eyes) enrolled from 1978 to 2015. The overall mortality rate was 24.2%. The overall 5-year survival rate was 63.4%, 73.8%, 89.1% in the three time periods respectively (P = 0.007). The 5-year survival improved continuously in both unilateral and bilateral disease (P = 0.057; P = 0.015). Patients without extraocular spreading or diagnosed before 2 years of age had a better 5- year survival of 97.4% and 81.1% respectively. The globe salvage rate improved from 8.2%, 14.5%, to 35.1% (P < 0.001). The globe salvage rate was 46.9% in patients who received ophthalmic artery chemosurgery (OAC) and 6.4% in patients not received OAC.

CONCLUSIONS

Improvement of survival and globe salvage rate was observed over time periods. National health insurance program has made medical care easily accessible to the public, leading to earlier diagnosis and treatment. Different treatment modes could achieve a better clinical outcome; among the new treatment modalities, OAC played an important role.

Lupeol induces autophagy and apoptosis with reduced cancer stem-like properties in retinoblastoma via phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin inhibition

OBJECTIVES

To evaluate the anticancer effects of lupeol in retinoblastoma cells.

METHODS

WERI-Rb-1 and Y-79 cell lines were used to evaluate the anticancer effect of lupeol. After lupeol treatment, the viability, proliferation, apoptosis, cancer stem-like properties, autophagy and in vivo tumour xenograft formation were detected.

KEY FINDINGS

In this study, lupeol decreased cell viability in both WERI-Rb-1 and Y-79 cell lines. Lupeol could also inhibit proliferation and induce apoptosis of RB cells, with increased Bax level and decreased Ki67, survivin and Bcl-2 levels. Furthermore, lupeol could suppress the spheroid formation and stem-like properties of RB cells. Moreover, LC3 II/LC3 I ratio and the levels of Beclin1 and ATG7 were increased after lupeol treatment, indicating that lupeol could induce autophagy in RB cells. Next, the inhibitory effect of lupeol on the phosphoinositide 3-kinase/protein kinase B/mammalian target of rapamycin pathway was observed. In tumour-bearing mice, lupeol suppressed tumour growth, and this might relate to its role in cell apoptosis, autophagy and stem-like properties.

CONCLUSIONS

Lupeol suppressed proliferation and cancer stem-like properties, and promoted autophagy and apoptosis of RB cells by restraining the PI3K/AKT/mTOR pathway.

Eye Salvage with Intra-Arterial and Intra-Vitreal Chemotherapy in Patients with Retinoblastoma: 8-Year Single-Institution Experience in Colombia

Introduction

Intra-arterial chemotherapy (IAC) is useful for eye preservation in advanced retinoblastoma (Rb). Intra-vitreal chemotherapy (IvitC) is the latest treatment for vitreous seeds.

Methods

The present study is a retrospective assessment of 100 eyes, treated with primary or secondary IAC alone or with IvitC. We evaluated demographic and clinical variables, eye salvage, associated adverse events, and patient survival. Data were analyzed using descriptive statistics. Kaplan-Meier survival curves and Cox hazard ratios were utilized to assess the effect of demographic and clinical variables over eye salvage.

Results

Bilateral Rb was observed in 61% of patients, and 57% of eyes received secondary treatment. Forty eyes needed intra-arterial plus IvitC and 62 presented advanced disease (group D and E). Three- and 5-year ocular survival probabilities were 75 and 68%. We found a higher risk in group D and E eyes and those requiring 2 or more routes for ophthalmic artery catheterization. Patients coming from other countries also showed increased risk. Using primary or secondary treatment, or IvitC, did not affect this risk. Overall rates of survival and eye salvages were 98.8 and 73%, and we had a 100% catheterization success and none ophthalmic arterial occlusions.

Conclusions

In an upper middle-income country such as Colombia, a specialized institution counting with therapeutic alternatives and a multidisciplinary team can reach rates of patient survival and eye salvage similar to those of high-income countries.

Increasing the efficiency of the retinoblastoma brachytherapy protocol with ultrasonic hyperthermia and gold nanoparticles: a rabbit model

PURPOSE

This study purposed to evaluate the efficacy of brachytherapy with the modality of ultrasonic hyperthermia in the presence of gold nanoparticles (GNPs) on an ocular retinoblastoma tumor in an animal model of the rabbit.

MATERIALS AND METHODS

A retinoblastoma tumor was induced by the injection of the human cell line of Y79 in rabbit eyes (n = 41). After two weeks, tumor size reached a diameter of about 5-7 mm. Seven groups were involved: control, GNPs injection, hyperthermia, hyperthermia with GNPs injection, brachytherapy with I-125, a combination of hyperthermia and brachytherapy, and a combination of brachytherapy, hyperthermia and, GNPs. The tumor area was measured using B-mode ultrasound images on the zero-day and at the end of the third week. The groups were evaluated for a histopathological study of tumor necrosis.

RESULTS

There was a significant difference between the relative area changes of tumor in the combination group with the other study groups (p < .05). The results of histopathologic studies confirmed the necrosis of living retinoblastoma cells.

CONCLUSION

Combination therapy of brachytherapy and hyperthermia with GNPs reduces the relative size of the tumor. This method increases the necrosis percentage of retinoblastoma and significantly reduces the retinoblastoma mass in the rabbit eyes.

[Tumors and Pseudotumors of the Retina and the Ciliary Epithelium]

The variety of retinal tumors ranges from harmless lesions to benign, locally destructive tumors and life-threatening diseases, and they are not always easy to distinguish from each other. The differential diagnosis includes real neoplasia, reactive inflammatory pathologies and vascular anomalies of the fundus as well. If possible, the diagnosis should be made clinically in order to avoid the danger of tumor cell spread via invasive diagnostic tools. Nevertheless, genetic analysis of the pathology is gaining more importance and adds to the precise characterization of the diagnosis. Depending on the tumor entity, therapy in a specialized center is necessary.

Tumoren und Pseudotumoren der Netzhaut und des Ziliarepithels

Die Varietät retinaler Tumoren reicht von harmlosen Läsionen über benigne, lokal destruierende Tumoren bis hin zu lebensbedrohlichen Erkrankungen. Nicht immer lassen sie sich einfach voneinander unterscheiden. Die Diagnose sollte nach Möglichkeit klinisch gestellt werden wegen der Gefahr einer Tumorzellverschleppung durch invasive Diagnostik. Jedoch rückt die genetische Charakterisierung der Läsion immer mehr in den Vordergrund. Je nach Entität ist eine Therapie in einem spezialisierten Zentrum notwendig.