1
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Kubo T, Sone M, Sugawara S, Kusumoto M, Arakawa A, Ogawa C, Suzuki S, Arai Y, Abe O. Technical Feasibility and Safety of Central Venous Ports for Intravenous Chemotherapy in Infants With Retinoblastoma: A Retrospective Study. Cureus 2024; 16:e52231. [PMID: 38352095 PMCID: PMC10861846 DOI: 10.7759/cureus.52231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE The central venous port (CVP) is widely used for intravenous chemotherapy (IVC) in adult patients because of its lower infection rates and easier management than that of a central venous catheter. However, the feasibility and safety of the CVP for IVC in infants remain unknown. This study evaluated the usefulness of CVP for IVC in infants with retinoblastoma. METHODS The usefulness of CVP was retrospectively evaluated using technical success rates, the safety of CVP placement, and postoperative procedure-related complications in 18 infants with retinoblastoma. This study was conducted at the National Cancer Center Hospital, Chuo-Ku, Tokyo, Japan. RESULTS The technical success rate was 100% (18/18) without any procedure-related complications. The sum duration of CVP implantation was 12,836 days (mean: 713 ± 453 days, range: 10-1,639 days). Postoperative complications were observed in two cases; one was a port reversal after 20 days, which was reversed by incisional surgery, and another was a catheter-related bloodstream infection after eight days, resulting in CVP removal. The total incidence of CVP-related infections was 5.6% (1/18) and 0.08/1000 catheter days. No other CVP-related complications were noted. CONCLUSION The use of the CVP for IVC in infants with retinoblastoma was feasible with few complications.
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Affiliation(s)
| | - Miyuki Sone
- Diagnostic Radiology, National Cancer Center Hospital, Tokyo, JPN
| | | | | | - Ayumu Arakawa
- Pediatric Oncology, National Cancer Center Hospital, Tokyo, JPN
| | - Chitose Ogawa
- Pediatric Oncology, National Cancer Center Hospital, Tokyo, JPN
| | - Shigenobu Suzuki
- Ophthalmic Oncology, National Cancer Center Hospital, Tokyo, JPN
| | - Yasuaki Arai
- Diagnostic Radiology, National Cancer Center Hospital, Tokyo, JPN
| | - Osamu Abe
- Radiology, The University of Tokyo Hospital, Tokyo, JPN
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2
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Zhang DL, French DD, Rossen JL, Rahmani B. Direct medical costs of globe salvage in group C-E retinoblastoma and implications for cost-effectiveness. J AAPOS 2023; 27:338.e1-338.e6. [PMID: 39195356 DOI: 10.1016/j.jaapos.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 08/29/2024]
Abstract
PURPOSE To determine the direct medical costs and cost-effectiveness of globe salvage compared with primary enucleation in patients with advanced retinoblastoma. METHODS Patients with International Classification of Retinoblastoma groups C-E retinoblastoma at a single institution from 2001 to 2021 were categorized into two groups: primary enucleation and globe salvage. Hospital visits and treatments were compared to determine differences in care utilization. Costs per encounter were derived from billing data and multiplied by number of encounters to determine total costs in the first year of treatment. Groups were stratified by unilateral or bilateral retinoblastoma, and visual acuity-based utility values were used to compare quality-adjusted life years to determine cost-effectiveness. RESULTS Of 74 group C-E eyes of 70 patients, 55 eyes underwent primary enucleation and 19 eyes underwent globe salvage, 12 of which ultimately underwent secondary enucleation. Patients who underwent globe salvage had higher usage of systemic chemotherapy (P = 0.001), more examinations under anesthesia (P < 0.001), fewer outpatient visits (P = 0.03), and a higher total cost of care (301,151 vs 104,764 USD [P < 0.001]) in the first year of treatment compared with the primary enucleation group. At an average life expectancy of 76 years, the incremental cost-effectiveness ratio was 118,347 USD per QALY in unilateral retinoblastoma and 32,987 USD per QALY in bilateral retinoblastoma, meeting the <150,000 USD/QALY threshold of cost-effectiveness. CONCLUSIONS Incurring additional costs may save the eye in advanced retinoblastoma, but the possibility of secondary enucleation should be disclosed for informed decision making. Despite this risk, globe salvage was cost-effective in unilateral and bilateral retinoblastoma.
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Affiliation(s)
- David L Zhang
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dustin D French
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer L Rossen
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Ophthalmology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Bahram Rahmani
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Ophthalmology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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3
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Belson PJ, Eastwood JA, Brecht ML, Kim JW, Hays RD, Pike NA. Health-Related Quality of Life in Adolescent and Young Adult Retinoblastoma Survivors. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2022; 39:342-357. [PMID: 35674414 PMCID: PMC9807776 DOI: 10.1177/27527530221073766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background: Retinoblastoma (RB) is a malignant intraocular tumor diagnosed in early childhood that requires extensive medical and surgical treatment at a young age. Health-related quality of life (HRQOL) is thought to be diminished due to visual impairment, facial deformities, and fear of recurrence or secondary cancer. However, few studies have identified variables associated with HRQOL among those with RB. Purpose: To compare HRQOL of adolescents and young adults (AYAs) with RB to matched controls and to identify predictors of HRQOL in RB survivors. Methods: Using a cross-sectional design, 198 AYAs (101 RBs and 97 controls) completed HRQOL (PROMIS®-29 profile) and psychosocial questionnaires (Rosenberg self-esteem scale, multidimensional scale of perceived social support, and Hollingshead index for socioeconomic status). Clinical variables (age at diagnosis, visual acuity, laterality, heredity, treatment regime, and anesthesia exposure) were extracted from the medical record. Correlates of HRQOL were estimated using linear regression models. Results: RB survivors reported similar HRQOL compared to controls. Physical function (p < .001), social support (p = .013), and self-esteem (p = .028) were lower in the RB group compared to controls. Visual acuity and self-esteem accounted for 52% of the variance in PROMIS physical health summary scores and self-esteem accounted for 38% of the variance in mental health summary scores. Conclusion: Despite deficits in physical function and self-esteem HRQOL in RB survivors was comparable to healthy counterparts. However, the majority of RB survivors in this study had normal visual acuity. Clinicians should explore ways to enhance self-esteem in RB survivors.
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Affiliation(s)
| | | | | | - Jonathan W. Kim
- Children’s Hospital, Los Angeles, CA, USA
- USC Roski Eye Institute, University of Southern California, Los
Angeles, CA, USA
| | - Ron D. Hays
- University of California, Los Angeles, CA, USA
- RAND Corporation, Santa Monica, CA, USA
| | - Nancy A. Pike
- Children’s Hospital, Los Angeles, CA, USA
- University of California, Los Angeles, CA, USA
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4
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Fabian ID, Shah V, Kapelushnik N, Naeem Z, Onadim Z, Price EA, Duncan C, Stansfield D, Sagoo MS, Reddy MA. Number, frequency and time interval of examinations under anesthesia in bilateral retinoblastoma. Graefes Arch Clin Exp Ophthalmol 2020; 258:879-886. [PMID: 31900643 DOI: 10.1007/s00417-019-04589-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/16/2019] [Accepted: 12/19/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Current practice in retinoblastoma (Rb) has transformed this malignancy into a curable disease. More attention should therefore be given to quality of life considerations, including measures related to examinations under anesthesia (EUAs). We aimed to investigate EUA measures in bilateral Rb patients and compare the findings to EUAs in unilateral Rb. METHODS A retrospective analysis of bilateral Rb patients that presented to the London Rb service from 2006 to 2013, were treated and had long-term follow-up. RESULTS A total of 62 Rb patients, 15 (24.2%) of which had International Intraocular Retinoblastoma Classification (IIRC) group A/B/no Rb at presentation, 26 (41.9%) C/D, and 21 (33.9%) were E in at least one eye. The mean number of EUAs was 35.8 ± 21.5, mean time from first to last EUA was 50.6 ± 19.9 months, and mean EUA frequency was 0.715 ± 0.293 EUAs/month. IIRC group was found not to correlate with any of the EUA measures. Age at presentation inversely correlated with time interval from first to last EUA and to EUA frequency (p ≤ 0.029). Rb family history correlated with the latter measure (p = 0.005) and intraophthalmic artery chemotherapy and brachytherapy correlated with all EUA measures (p ≤ 0.029). Mean follow-up time was 80.1 ± 24.3 months. When compared with a previously reported cohort of unilateral Rb, the present group underwent 3× more EUAs (p < 0.001) over nearly double the time (p < 0.001). CONCLUSIONS Families should be counselled on anticipated EUA burden associated with bilateral Rb. In this respect, age at presentation and family history were found to have a predictive role, whereas IIRC group did not.
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Affiliation(s)
- Ido Didi Fabian
- Retinoblastoma Service, Royal London Hospital, London, UK. .,Moorfields Eye Hospital, London, UK. .,Ocular Oncology Service, Goldschleger Eye Institute, Sheba Medical Center, Tel-Aviv University, Tel Aviv, Israel.
| | | | - Noa Kapelushnik
- Ocular Oncology Service, Goldschleger Eye Institute, Sheba Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Zishan Naeem
- Retinoblastoma Service, Royal London Hospital, London, UK
| | - Zerrin Onadim
- Retinoblastoma Service, Royal London Hospital, London, UK
| | | | - Catriona Duncan
- Retinoblastoma Service, Royal London Hospital, London, UK.,Paediatric Oncology Department, Great Ormond Street Hospital, London, UK
| | | | - Mandeep S Sagoo
- Retinoblastoma Service, Royal London Hospital, London, UK.,Moorfields Eye Hospital, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - M Ashwin Reddy
- Retinoblastoma Service, Royal London Hospital, London, UK.,Moorfields Eye Hospital, London, UK
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5
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Fabian ID, Shah V, Kapelushnik N, Naeem Z, Onadim Z, Price E, Chowdhury T, Duncan C, Stansfield D, Sagoo M, Reddy MA. Examinations under anaesthesia as a measure of disease burden in unilateral retinoblastoma: the London experience. Br J Ophthalmol 2019; 104:17-22. [PMID: 30862620 DOI: 10.1136/bjophthalmol-2018-313556] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/19/2019] [Accepted: 02/23/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Early diagnosis strategies and advances in retinoblastoma (Rb) management have resulted in nearly 100% survival. More attention should, therefore, be given to quality of life considerations. We aimed to quantify the number of examinations under anaesthesia (EUAs) in a cohort of patients with Rb, as a measure of disease burden. METHODS A retrospective analysis of patients with unilateral Rb that presented to the London Rb service from 2006 to 2013, were treated and had long-term follow-up. Correlations of clinical variables to number of EUAs were investigated. RESULTS A total of 107 patients with Rb were included that presented at a mean age of 26.51 ± 22.68 months. The International Intraocular Retinoblastoma Classification (IIRC) was group B in 5 (5%), C in 13 (12%), D in 48 (45%) and E in 41 (38%) of the cases. Primary treatment was intravenous chemotherapy in 36 (34%) and enucleation in 71 (66%) of the cases. Mean number of EUAs was 20.67 ± 6.62, 12.52 ± 6.23 and 11.15 ± 6.91 for combined groups B/C, group D and group E patients (p < 0.001), respectively. On analysis, early age atpresentation and conservative treatments were found to significantly correlate with increased number of EUAs (p < 0.001). Mean follow-up time was 74.42 ± 25.16 months and no metastasis or death were reported. CONCLUSION Families should be counselled regarding the number of EUAs associated with the patient's IIRC group, with B/C eyes undergoing twice the number as compared with D/E eyes. For group D cases, where both enucleation and conservative therapy are valid options, treatment choice has a significant impact on the number of EUAs.
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Affiliation(s)
- Ido Didi Fabian
- Moorfields Eye Hospital, London, UK .,Retinoblastoma Service, Royal London Hospital, London, UK.,Ocular Oncology Service, Goldschleger Eye Institute, Sheba Medical Center,Tel-Aviv University, Tel Aviv, Israel
| | | | - Noa Kapelushnik
- Ocular Oncology Service, Goldschleger Eye Institute, Sheba Medical Center,Tel-Aviv University, Tel Aviv, Israel
| | - Zishan Naeem
- Retinoblastoma Service, Royal London Hospital, London, UK
| | - Zerrin Onadim
- Retinoblastoma Service, Royal London Hospital, London, UK
| | | | - Tanzina Chowdhury
- Retinoblastoma Service, Royal London Hospital, London, UK.,Paediatric Oncology Department, Great Ormond Street Hospital, London, UK
| | - Catriona Duncan
- Retinoblastoma Service, Royal London Hospital, London, UK.,Paediatric Oncology Department, Great Ormond Street Hospital, London, UK
| | | | - Mandeep Sagoo
- Retinoblastoma Service, Royal London Hospital, London, UK.,NIHR Biomedical Research Centre for Ophthalmology at University CollegeLondon, Institute of Ophthalmology and Moorfields Eye Hospital, London, UK
| | - Maddy Ashwin Reddy
- Moorfields Eye Hospital, London, UK.,Retinoblastoma Service, Royal London Hospital, London, UK
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6
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Funes S, Sampor C, Villasante F, Fandiño A, Manzitti J, Sgroi M, Neira P, Peralta L, Lagomarsino E, Schaiquevich P, Ceciliano A, Chantada GL. Feasibility and results of an intraarterial chemotherapy program for the conservative treatment of retinoblastoma in Argentina. Pediatr Blood Cancer 2018; 65:e27086. [PMID: 29693791 DOI: 10.1002/pbc.27086] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 02/28/2018] [Accepted: 03/10/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND The feasibility and results of intraarterial chemotherapy, also termed ophthalmic artery chemosurgery (OAC), for retinoblastoma in less developed countries have seldom been reported. PROCEDURE A retrospective evaluation of a program of OAC in Argentina from 2010 to 2015. RESULTS Ninety-seven eyes from 81 patients (61 bilateral) were analyzed. In 35 eyes, OAC was given as primary therapy and in 62 it was used for the treatment of tumors with partial response or those relapsing after systemic chemoreduction with focal therapy or external-beam radiotherapy. Twenty-two primarily treated eyes had group D and 13 groups B/C. A total of 400 procedures were carried out. Chemotherapy used included combinations of melphalan, carboplatin, and topotecan. There was no mortality associated with OAC. Toxicity included fever and neutropenia in five (1.25%), hypotension and bradycardia during anesthesia in two and femoral thrombosis in one, eyelid edema in nine, and neutropenia or thrombocytopenia in 28 cycles. With a median follow-up of 48.7 months (range 12-79), the 3-year probability of event-free survival (pEFS) (enucleation and/or radiotherapy were considered events) was comparable for patients who received first-line therapy and those treated at relapse (0.65 vs. 0.63, P = 0.5). In the former, the pEFS was 0.91 and 0.43 for groups B/C and D, respectively (P = 0.01). Two patients died of extraocular dissemination after refusal of enucleation. CONCLUSIONS OAC was feasible with low toxicity. pEFS improved in all groups compared to the previous experience with systemic chemotherapy reducing the use of radiotherapy. The overall mortality associated with OAC is comparable to our previous experience with systemic chemoreduction.
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Affiliation(s)
- Santiago Funes
- Pediatric Hemato-Oncology Service, Hospital Universitario Austral, Pilar, Argentina
| | - Claudia Sampor
- Hematology-Oncology Service, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Francisco Villasante
- Department of Interventional Neuroradiology, Hospital Universitario Austral, Pilar, Argentina
| | - Adriana Fandiño
- Department of Ophthalmology, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Julio Manzitti
- Department of Ophthalmology, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Mariana Sgroi
- Department of Ophthalmology, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Pablo Neira
- Department of Pediatrics, Clinica y Maternidad Suizo Argentina, Buenos Aires, Argentina
| | - Laura Peralta
- Department of Clinical Pediatrics, Hospital JP Garrahan, Buenos Aires, Argentina
| | | | - Paula Schaiquevich
- Clinical Pharmacokinetics Unit, Hospital JP Garrahan, CONICET, Buenos Aires, Argentina
| | - Alejandro Ceciliano
- Department of Interventional Neuroradiology, Hospital Universitario Austral, Pilar, Argentina
| | - Guillermo L Chantada
- Pediatric Hemato-Oncology Service, Hospital Universitario Austral, Pilar, Argentina.,Hematology-Oncology Service, Hospital JP Garrahan, Buenos Aires, Argentina
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7
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Fabian ID, Stacey AW, Johnson KC, Chowdhury T, Duncan C, Reddy MA, Sagoo MS. Primary enucleation for group D retinoblastoma in the era of systemic and targeted chemotherapy: the price of retaining an eye. Br J Ophthalmol 2017; 102:265-271. [PMID: 28659391 DOI: 10.1136/bjophthalmol-2017-310624] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chemotherapy is increasingly used as primary treatment for group D retinoblastoma, whereas primary enucleation is considered to have a diminishing role. This study aimed to compare the management course, including number of examinations under anaesthesia (EUAs), of group D patients treated by enucleation versus chemotherapy. METHODS A retrospective analysis of 92 group D patients, of which 40 (37 unilateral) underwent primary enucleation and 52 (17 unilateral) were treated with intravenous chemotherapy. Number of EUAs was compared between the treatment groups with respect to the whole cohort, using univariate and multivariate analysis, and to unilateral cases only. RESULTS Patients were followed up for a median of 61 months (mean: 66, range: 14-156), in which time primary enucleated patients had on average seven EUAs and chemotherapy-treated patients 21 EUAs (p<0.001). Chemotherapy, young age, bilateral disease, multifocal tumours, familial and germline retinoblastoma were found on univariate analysis to correlate with increased number of EUAs (p≤0.019). On multivariate analysis, however, only treatment type and presentation age were found significant (p≤0.001). On subanalysis of the unilateral cases, patients undergoing primary enucleation had in average seven EUAs, as compared with 16 in the chemotherapy group (p<0.001). Of the 55 unilateral-presenting patients, a new tumour developed in the fellow eye only in a single familial case. CONCLUSION Group D patients' families should be counselled regarding the significant difference in number of EUAs following primary enucleation versus chemotherapy when deciding on a treatment strategy. In this regard, primary enucleation would be most beneficial for older patients with unilateral disease.
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Affiliation(s)
- Ido D Fabian
- Ocular Oncology Service, Moorfields Eye Hospital, London, UK.,Retinoblastoma Service, Royal London Hospital, London, UK.,Ocular Oncology Service, Goldschleger Eye Institute, Sheba Medical Center, Tel-Aviv University, Tel Aviv, Israel
| | - Andrew W Stacey
- Ocular Oncology Service, Moorfields Eye Hospital, London, UK.,Retinoblastoma Service, Royal London Hospital, London, UK.,Department of Ophthalmology, University of Washington, Seattle, Washington, USA
| | | | - Tanzina Chowdhury
- Retinoblastoma Service, Royal London Hospital, London, UK.,Department of Paediatric Oncology, Great Ormond Street Hospital, London, UK
| | - Catriona Duncan
- Retinoblastoma Service, Royal London Hospital, London, UK.,Department of Paediatric Oncology, Great Ormond Street Hospital, London, UK
| | - M Ashwin Reddy
- Retinoblastoma Service, Royal London Hospital, London, UK
| | - Mandeep S Sagoo
- Ocular Oncology Service, Moorfields Eye Hospital, London, UK.,Retinoblastoma Service, Royal London Hospital, London, UK.,University College London, Institute of Ophthalmology, London, UK
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8
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Nagayoshi M, Hirose T, Toju K, Suzuki S, Okamitsu M, Teramoto T, Omori T, Kawamura A, Takeo N. Related visual impairment to mother-infant interaction and development in infants with bilateral retinoblastoma. Eur J Oncol Nurs 2017; 28:28-34. [PMID: 28478852 DOI: 10.1016/j.ejon.2017.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 01/22/2017] [Accepted: 02/16/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE This study was conducted with infants diagnosed with bilateral retinoblastoma (RB) and their mothers. It explored characteristics of the mother-infant interaction, the infants' developmental characteristics and related risk factors. METHOD Cross-sectional statistical analysis was performed with 18 dyads of one-year-old infants with bilateral RB and their mothers. RESULTS Using the Japanese Nursing Child Assessment Teaching Scale (JNCATS) results showed that infants with RB had significantly lower scores compared to normative Japanese scores on all of the infants' subscales and "Child's contingency" (p < 0.01). Five infants with visual impairment at high risk of developmental problems had a pass rate of 0% on six JNCATS items. There were positive correlations between Developmental quotients (DQ) and JNCATS score of "Responsiveness to caregiver" (ρ = 0.50, p < 0.05) and DQ and "Child's contingency" (ρ = 0.47, p < 0.05). CONCLUSIONS Infants with visual impairment were characterized by high likelihood of developmental delays and problematic behaviors; they tended not to turn their face or eyes toward their mothers, smile in response to their mothers' talking to them or the latter's changing body language or facial expressions, or react in a contingent manner in their interactions. These infant behaviors noted by their mothers shared similarities with developmental characteristics of children with visual impairments. These findings indicated a need to provide support promoting mother-infant interactions consistent with the developmental characteristics of RB infants with visual impairment.
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Affiliation(s)
- Michie Nagayoshi
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Taiko Hirose
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Kyoko Toju
- Department of Nursing, National Cancer Center Hospital East, 6-5-1, Kashiwanoha Kashiwa-shi, Chiba-ken, 277-8577, Japan
| | - Shigenobu Suzuki
- Department of Ophthalmic Oncology, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Motoko Okamitsu
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Taeko Teramoto
- Department of Human Psychology, Faculty of Liberal Arts, Kaichi International University, 1225-6, Kashiwa, Kashiwa, Chiba, 277-0005, Japan
| | - Takahide Omori
- Department of Psychology, Keio University, 2-15-45, Mita, Minato-ku, Tokyo, 108-8345, Japan
| | - Aki Kawamura
- Faculty of Nursing and Nutrition Department of Nursing, Shukutoku University, 673, Nitona-cho, Chuo-ku, Chiba, Japan
| | - Naoko Takeo
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
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9
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Green AL, Chintagumpala M, Krailo M, Langholz B, Albert D, Eagle R, Cockburn M, Chevez-Barrios P, Rodriguez-Galindo C. Correlation of Insurance, Race, and Ethnicity with Pathologic Risk in a Controlled Retinoblastoma Cohort: A Children's Oncology Group Study. Ophthalmology 2016; 123:1817-1823. [PMID: 27262763 DOI: 10.1016/j.ophtha.2016.04.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 04/21/2016] [Accepted: 04/22/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To determine whether insurance status, race, and ethnicity correlate with increased retinoblastoma invasiveness as a marker of both risk and time to diagnosis. DESIGN Retrospective case-control study. PARTICIPANTS All 203 patients from the United States enrolled in the Children's Oncology Group (COG) trial ARET0332, a study of patients with unilateral retinoblastoma requiring enucleation. MAIN OUTCOME MEASURES All surgical specimens underwent pathologic review to determine the presence of well-defined histopathologic features correlating with a higher risk of disease progression. Insurance status, race, and ethnicity were compiled from the study record for each patient. RESULTS On institutional pathologic review, nonprivate insurance, nonwhite race, and Hispanic ethnicity all correlated significantly with a greater rate of high-risk pathologic findings. Hispanic ethnicity remained a significant predictor on multivariate analysis. On central pathologic review, these correlations remained but did not reach statistical significance. The differences in results from institutional versus central pathologic reviews appeared to be due to a higher likelihood of patients in minority groups of being misclassified as high risk by institutional pathologists. CONCLUSIONS In this controlled study population of patients with retinoblastoma who had central pathologic review, our findings suggest a higher rate of more advanced disease associated with nonprivate insurance, nonwhite race, and Hispanic ethnicity; these findings may be due to delays in diagnosis for these groups. Future work should use direct methods to study the impact of other variables, including English-language proficiency and socioeconomic status. Further effort also should focus on where in the diagnostic process potential delays exist, so that interventions can be designed to overcome barriers to care for these groups. In addition, potential systematic differences in pathologic reads based on demographic variables deserve further study.
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Affiliation(s)
- Adam L Green
- Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado.
| | - Murali Chintagumpala
- Texas Children's Cancer Center, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mark Krailo
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Bryan Langholz
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniel Albert
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Ralph Eagle
- Pathology Department, Wills Eye Hospital, Philadelphia, Pennsylvania
| | - Myles Cockburn
- Keck School of Medicine of the University of Southern California, Los Angeles, California
| | | | - Carlos Rodriguez-Galindo
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
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10
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Nagayoshi M, Hirose T, Toju K, Suzuki S, Okamitsu M, Omori T, Kawamura A, Takeo N. Parenting stress related to raising infants receiving treatment for retinoblastoma. Psychooncology 2016; 25:1507-1511. [PMID: 26775835 DOI: 10.1002/pon.4062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/15/2015] [Accepted: 11/25/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Michie Nagayoshi
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taiko Hirose
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kyoko Toju
- Department of Nursing, National Cancer Center Hospital, Tokyo, Japan
| | - Shigenobu Suzuki
- Department of Ophthalmic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Motoko Okamitsu
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Aki Kawamura
- Faculty of Nursing and Nutrition, Department of Nursing, Shukutoku University, Chiba, Japan
| | - Naoko Takeo
- Graduate School of Health Care Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Soliman SE, Dimaras H, Souka AA, Ashry MH, Gallie BL. Socioeconomic and psychological impact of treatment for unilateral intraocular retinoblastoma. J Fr Ophtalmol 2015; 38:550-8. [PMID: 25982424 DOI: 10.1016/j.jfo.2015.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 03/12/2015] [Accepted: 03/20/2015] [Indexed: 02/08/2023]
Abstract
PURPOSE To identify the socioeconomic and psychosocial impacts of clinical treatment decisions for advanced unilateral intraocular retinoblastoma. DESIGN Retrospective observational case series. METHODS SETTING institutional study at Alexandria Main University Hospital. STUDY POPULATION records of 66 unilateral retinoblastoma cases treated from May 2005 to May 2013 were retrospectively reviewed. Sixty cases were eligible (International Intraocular Retinoblastoma Classification [IIRC] group C, D or E). PROCEDURES two treatment groups were compared: enucleation vs. salvage treatment. Salvage treatment eyes were further subdivided based on IIRC group. Six socioeconomic parameters (financial burden, financial impact, psychological, social, medical and tumor impacts) were scored. Parameter scores ranged from 0 to 3, for overall score range 0 (no adverse impact) to 18 (severe adverse impact). MAIN OUTCOME MEASURES derived Socioeconomic scores were correlated with treatment and outcomes. RESULTS The enucleation group (28 eyes) had a median overall Socioeconomic score of 4/18, significantly lower than the salvage treatment group (32 eyes), median score 11/18 (P<0.01). Socioeconomic score varied with IIRC group. Attempted eye salvage failed in 25 children, due to uncontrolled tumor (44%) and socioeconomic impact of cumulative therapies (56%). Treatment duration and Socioeconomic score were higher for the 5 children in the salvage treatment group who developed metastatic disease compared to those without metastasis (P<0.01). CONCLUSIONS The socioeconomic and psychosocial impacts of attempted ocular salvage for unilateral intraocular retinoblastoma are severe, in comparison to primary enucleation. Primary enucleation is a good treatment for unilateral retinoblastoma.
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Affiliation(s)
- S E Soliman
- Ophthalmology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Ophthalmology & Visual Sciences, University of Toronto, Toronto, Canada; The Hospital for Sick Children Research Institute, 555 University Avenue, Room 7265, Toronto ON M5G 1X8, Canada.
| | - H Dimaras
- Department of Ophthalmology & Visual Sciences, University of Toronto, Toronto, Canada; The Hospital for Sick Children Research Institute, 555 University Avenue, Room 7265, Toronto ON M5G 1X8, Canada; Division of Visual Science, Toronto Western Research Institute, Toronto, Canada
| | - A A Souka
- Ophthalmology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - M H Ashry
- Community Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - B L Gallie
- Department of Ophthalmology & Visual Sciences, University of Toronto, Toronto, Canada; The Hospital for Sick Children Research Institute, 555 University Avenue, Room 7265, Toronto ON M5G 1X8, Canada; Division of Visual Science, Toronto Western Research Institute, Toronto, Canada; Department of Ophthalmology & Visual Science, Hospital for Sick Children, Toronto, Canada; Princess Margaret Cancer Centre, Toronto, Canada; Departments of Ophthalmology & Visual Sciences, Medical Biophysics and Molecular Genetics, University of Toronto, Toronto, Canada
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Chantada GL, Fandiño AC, Schvartzman E, Raslawski E, Schaiquevich P, Manzitti J. Impact of chemoreduction for conservative therapy for retinoblastoma in Argentina. Pediatr Blood Cancer 2014; 61:821-6. [PMID: 24243706 DOI: 10.1002/pbc.24857] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 10/18/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Few studies were reported from developing countries regarding patient outcome and ocular survival in children with bilateral retinoblastoma treated with chemoreduction compared to external beam radiotherapy (EBRT). PROCEDURE We undertook a retrospective study of three treatment eras: (1) (1988-1995) n = 68 when EBRT was used as primary conservative therapy; (2) (1995-2003) n = 46 when carboplatin-based systemic chemoreduction was introduced and (3) (2003-2009) (n = 83) when additional periocular chemotherapy was added for advanced tumors and pre-enucleation chemotherapy was given for those with massive buphthalmia. RESULTS The probability of 5-year disease-free survival was 0.94 (95% confidence interval [CI] 0.91-0.98%) without significant differences among the three eras. Chemoreduction reduced the use of EBRT from 84.6% to 68.7% in eras 1 and 3, respectively (P = 0.008), which was more evident in cases with less advanced disease. Chemoreduction also significantly improved the 5-year probability of preservation of eyes with advanced disease from 0.13 (95% CI 0.04-0.27) during era 1 to 0.49 (95% CI 0.34-0.62) in era 3 (P < 0.0001). Chemoreduction was not associated with changes in the probability of extraocular relapse, which was reduced after the introduction of pre-enucleation chemotherapy. Second malignancies occurred in nine cases, acute myeloid leukemia being the most fatal one. Trilateral retinoblastoma occurred in three cases and all of them had been exposed to chemotherapy. CONCLUSIONS Chemoreduction reduced the need for EBRT in eyes with less advanced disease and improved the preservation of eyes with advanced disease while its effects on secondary malignancies or trilateral disease remain unclear.
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Chantada G, Luna-Fineman S, Sitorus RS, Kruger M, Israels T, Leal-Leal C, Bakhshi S, Qaddoumi I, Abramson DH, Doz F. SIOP-PODC recommendations for graduated-intensity treatment of retinoblastoma in developing countries. Pediatr Blood Cancer 2013; 60:719-27. [PMID: 23335388 DOI: 10.1002/pbc.24468] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 12/13/2012] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Guillermo Chantada
- Hospital de Pediatria SAMIC Prof Dr Juan P Garrahan, Buenos Aires, Argentina.
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Khurana A, Eisenhut CA, Wan W, Ebrahimi KB, Patel C, O'Brien JM, Yeom K, Daldrup-Link HE. Comparison of the diagnostic value of MR imaging and ophthalmoscopy for the staging of retinoblastoma. Eur Radiol 2012; 23:1271-80. [PMID: 23160663 DOI: 10.1007/s00330-012-2707-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 10/02/2012] [Accepted: 10/07/2012] [Indexed: 01/09/2023]
Abstract
PURPOSE To compare the diagnostic value of magnetic resonance (MR) imaging and ophthalmoscopy for staging of retinoblastoma. METHODS MR and ophthalmoscopic images of 36 patients who underwent enucleation were evaluated retrospectively following institutional review board approval. Histopathology being the standard of reference, the sensitivity and specificity of both diagnostic modalities were compared regarding growth pattern, iris neoangiogenesis, retinal detachment, vitreous seeds and optic nerve invasion. Data were analysed via McNemar's test. RESULTS Both investigations showed no significant difference in accuracy for the detection of different tumour growth patterns (P = 0.80). Vitreous seeding detection was superior by ophthalmoscopy (P < 0.001). For prelaminar optic nerve invasion, MR imaging showed similar sensitivity as ophthalmoscopy but increased specificity of 40 % (CI 0.12-0.74) vs. 20 % (0.03-0.56). MR detected optic nerve involvement past the lamina cribrosa with a sensitivity of 80 % (0.28-0.99) and a specificity of 74 % (0.55-0.88). The absence of optic nerve enhancement excluded histopathological infiltration, but the presence of optic nerve enhancement included a high number of false positives (22-24 %). CONCLUSIONS Ophthalmoscopy remains the method of choice for determining extent within the globe while MR imaging is useful for evaluating extraocular tumour extension. Thus, both have their own strengths and contribute uniquely to the staging of retinoblastoma. KEY POINTS • Ophthalmoscopy: method of choice for determining extent of retinoblastoma within the globe. • MR imaging provides optimal evaluation of extrascleral and extraocular tumour extension. • Positive enhancement of the optic nerve on MRI does not necessarily indicate involvement.
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Affiliation(s)
- Aman Khurana
- Department of Radiology, Stanford University, Stanford, CA, USA
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Ji X, Xuan Y, Li J, Zhao J, Lu S, Zhang J, Yan H, Zhao P. Direct costs for retinoblastoma treatment during the first year of comprehensive therapy in China. J Pediatr Ophthalmol Strabismus 2012; 49:353-8. [PMID: 22800796 DOI: 10.3928/01913913-20120710-04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 05/30/2012] [Indexed: 11/20/2022]
Abstract
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.
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Rodriguez-Galindo C. The basics of retinoblastoma: back to school. Pediatr Blood Cancer 2011; 57:1093-4. [PMID: 22095928 DOI: 10.1002/pbc.23305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 07/14/2011] [Indexed: 11/10/2022]
Affiliation(s)
- Carlos Rodriguez-Galindo
- Dana-Farber/Children's Hospital Cancer Center, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Chantada GL, Qaddoumi I, Canturk S, Khetan V, Ma Z, Kimani K, Yeniad B, Sultan I, Sitorus RS, Tacyildiz N, Abramson DH. Strategies to manage retinoblastoma in developing countries. Pediatr Blood Cancer 2011; 56:341-8. [PMID: 21225909 DOI: 10.1002/pbc.22843] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 08/30/2010] [Indexed: 11/06/2022]
Abstract
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.
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Sultan I, Wilson MW, Nawaiseh I, Mehyar M, Kharma S, Al-Qudimat M, Hazin R, Alalami A, Jaradat I, Al-Husseini M, Abdeen G, Rodriguez-Galindo C, Qaddoumi I. Enucleation for retinoblastoma: the experience of a single center in Jordan. Int Ophthalmol 2010; 30:407-14. [DOI: 10.1007/s10792-010-9370-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Accepted: 04/05/2010] [Indexed: 11/30/2022]
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Chen YH, Lin HY, Hsu WM, Lee SM, Cheng CY. Retinoblastoma in Taiwan: incidence and survival characteristics from 1979 to 2003. Eye (Lond) 2009; 24:318-22. [DOI: 10.1038/eye.2009.80] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Balaguer J, Wilson MW, Billups CA, Mancini J, Haik BG, Qaddoumi I, Khoury JD, Rodriguez-Galindo C. Predictive factors of invasion in eyes with retinoblastoma enucleated after eye salvage treatments. Pediatr Blood Cancer 2009; 52:351-6. [PMID: 19021223 PMCID: PMC4643656 DOI: 10.1002/pbc.21845] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The impact of chemotherapy, focal therapies, radiation and co-existing ocular morbidities on histology of eyes with retinoblastoma enucleated following chemoreduction is not well known. PROCEDURE Twenty-five eyes (23 patients) with retinoblastoma enucleated after failing eye-salvage therapy were evaluated. Reasons for enucleation (tumor progression, subretinal or vitreous seeds) and co-morbid conditions (neovascular glaucoma, cataract, vitreous hemorrhage and retinal detachment) were documented. All specimens were reviewed for evidence of ciliary body, choroidal, optic nerve, and scleral invasion. RESULTS The median age at diagnosis was 14 months (range, 1-37 months). Twenty eyes were classified as Reese-Ellsworth Group IV-V at diagnosis. Twenty-four eyes had recurrent disease at enucleation; one eye was enucleated for neovascular glaucoma and vitreous hemorrhage. Co-existing ocular morbidities at enucleation included vitreous hemorrhage (n = 6), retinal detachment (n = 9), neovascular glaucoma (n = 9) and cataracts (n = 3). Histologic findings included choroidal invasion (n = 7), ciliary body invasion (n = 4), optic nerve invasion (n = 6) and scleral invasion (n = 3). The median time from diagnosis to enucleation was 11 months. Co-existing retinal detachment and vitreous hemorrhage significantly increased the likelihood of optic nerve invasion (P = 0.014 and P = 0.011, respectively). Prolonged time to enucleation was significantly associated with the likelihood of choroidal (P = 0.010) and ciliary body (P = 0.021) invasion as well as invasion of multiple sites. CONCLUSION In eyes with retinoblastoma enucleated after chemoreduction, co-existing ocular morbidities and time to enucleation are predictive of extra-retinal extension.
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Affiliation(s)
- Julia Balaguer
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Matthew W. Wilson
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN,Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN,Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Sciences Center, Memphis, TN
| | | | - John Mancini
- Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Sciences Center, Memphis, TN
| | - Barrett G. Haik
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN,Department of Ophthalmology, Hamilton Eye Institute, University of Tennessee Health Sciences Center, Memphis, TN
| | - Ibrahim Qaddoumi
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN,Department of Pediatrics, Hamilton Eye Institute, University of Tennessee Health Sciences Center, Memphis, TN
| | - Joseph D. Khoury
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Carlos Rodriguez-Galindo
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN,Department of Pediatrics, Hamilton Eye Institute, University of Tennessee Health Sciences Center, Memphis, TN
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