Modern treatment of retinoblastoma: A 2020 review

Retinoblastoma with and without Extraocular Tumor Extension: A Global Comparative Study of 3435 Patients

Purpose

To study the treatment and outcomes of children with retinoblastoma (RB) with extraocular tumor extension (RB-EOE) and compare them with RB without extraocular tumor extension (RB-w/o-EOE).

Design

Multicenter intercontinental collaborative prospective study from 2017 to 2020. RB-EOE cases included those with overt orbital tumor extension in treatment-naive patients. Cases with microscopic orbital extension detected postenucleation were excluded from the study.

Participants

A total of 319 children with RB-EOE and 3116 children with RB-w/o-EOE.

Intervention

Chemotherapy, enucleation, exenteration, radiotherapy.

Main Outcome Measures

Systemic metastasis and death.

Results

Of the 3435 RB patients included in this study, 309 (9%) were from low-income countries (LIC), 1448 (42%) from lower-middle income, 1012 (29%) from upper-middle income, and 666 (19%) patients from high-income countries. There was an inverse relationship between the percentage of RB-EOE and national income level, with 96 (31%) patients from LIC, 197 (6%) lower-middle income, 20 (2%) upper-middle income, and 6 (1%) patients from high-income countries (P = 0.0001). The outcomes were statistically significant for RB-EOE compared with RB-w/o-EOE: systemic metastasis (32% vs. 4% respectively; P = 0.0001) and metastasis-related death (63% vs. 6% respectively; P = 0.0001). Multimodal treatment was the most common form of treatment (n = 177; 54%) for RB-EOE, with most cases undergoing a combination of intravenous chemotherapy and enucleation (n = 97; 30%). Adjuvant external beam radiotherapy (EBRT) after surgery (enucleation/orbital exenteration) was given in only 68 (21%) cases. Kaplan-Meier analysis for systemic metastasis and metastasis-related death in RB-EOE was 28% and 57% at 1 year, 29% and 60% at 2 years, and 29% and 61% at 3 years, respectively. Cox regression analysis revealed that the risk of death from RB-EOE was greater in patients aged >4 years than <2 years (hazard ratio, 2.912; P < 0.001) and for unimodal (surgery or intravenous chemotherapy) and bimodal (surgery and intravenous chemotherapy) treatment than trimodal treatment (surgery, intravenous chemotherapy, and EBRT) (hazard ratio, 2.023; P = 0.004 and hazard ratio, 1.819; P = 0.027, respectively).

Conclusions

Retinoblastoma with extraocular tumor extension is associated with a higher risk of metastasis and death. Patients with RB-EOE are likely to benefit from trimodal treatment (intravenous chemotherapy, surgery, and EBRT) rather than treatment protocols excluding EBRT.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

Expression of Wnt signaling proteins LEF1, β-catenin, GSK3β, DVL1, and N-myc varies across retinoblastoma subtypes and pRb phosphorylation status

Retinoblastoma, a rare childhood eye cancer, has hereditary and non-hereditary forms. While TNM classification helps in prognosis, understanding molecular mechanisms is vital for the clinical behavior of retinoblastoma prediction. Our study aimed to analyze the expression levels of key Wnt pathway proteins, GSK3β, LEF1, β-catenin, and DVL1, and associate them to non-phosphorylated active form (pRb) and the phosphorylated inactive form (ppRb) and N-myc expression, in retinoblastoma cells and healthy retinal cells, in order to elucidate their roles in retinoblastoma and identify potential targets that could help to improve diagnostic and therapy. Specimens from 22 retinoblastoma cases (unilateral, bilateral, and trilateral) were analyzed. Immunohistochemistry assessed proteins' expressions, followed by semi-quantitative analysis using the Immunoreactivity Score (IRS). Bayesian statistical methods were employed for data analysis. The study revealed various expression patterns of Wnt signaling proteins across different retinoblastoma types. The high expression levels were observed for LEF1 and DVL1. Inactive GSK3β and nuclear localization of β-catenin indicated Wnt signaling activation. The levels of inactive ppRb were significantly higher in retinoblastoma compared to healthy retina, as well as the levels of inactive GSK3β. Positive correlations between DVL1 and N-myc, GSK3β Y216 and GSK3β S9 and non-P β-catenin and LEF1 were established. Retinoblastomas without germline mutations (RB1+/+) exhibited high pRb, N-myc, and LEF1 levels, while those in genetically predisposed children (RB1+/-) showed lower expression of these proteins. Trilateral retinoblastomas demonstrated especially high N-myc and LEF1, but low pRb and ppRb levels. The findings highlight the meaningful role of the Wnt signaling pathway in retinoblastoma pathogenesis, providing insights into potential therapeutic targets. Understanding molecular features may pave the way for personalized treatments and improve outcomes for retinoblastoma patients.

β-Asarone Inhibits Carboplatin Resistance in Retinoblastoma Cells Through the UCA1/miR-206/NRP1 Axis

Retinoblastoma (RB) is an aggressive form of eye cancer. β-Asarone is a bioactive component isolated from the medicinal plant Acorus tatarinowii Schott and has anticancer effects on various human cancers. However, reports regarding the role of β-Asarone in RB remain limited. Our study investigates the mechanisms of β-Asarone in regulating drug resistance in RB, providing a theoretical foundation for RB treatment. A carboplatin-resistant RB cell line was established and treated with β-Asarone, followed by overexpression of long non-coding RNA (lncRNA) urothelial carcinoma-associated 1 (UCA1). The half-maximal inhibitory concentration and cell apoptosis were determined. The levels of lncRNA UCA1/miR-206/neuropilin 1 (NRP1) were measured. The subcellular localization of lncRNA UCA1 was examined. The binding relationships between lncRNA UCA1 and microRNA (miR)-206, and between miR-206 and NRP1 were analyzed. NRP1 expression was analyzed by Western blot assay. We found that β-Asarone downregulated lncRNA UCA1 expression in carboplatin-resistant RB cells. Overexpression of lncRNA UCA1 reversed the inhibitory effect of β-Asarone on cell drug resistance and cell proliferation and reduced apoptosis. LncRNA UCA1 functioned as a sponge for miR-206, which suppressed NRP1 expression. Inhibition of miR-206 or overexpression of NRP1 could partially reverse the suppressive effect of β-Asarone on RB cell drug resistance. In conclusion, β-Asarone suppresses RB cell drug resistance through the lncRNA UCA1/miR-206/NRP1 axis.

Advancements in Ocular Modelling and Simulations: Key Considerations and Case Studies

This review paper discusses the key aspects of ocular biopharmaceutics, with emphasis on the crucial role played by ocular compartmental modelling and simulation in deciphering physiological conditions related to various eye diseases. It describes eye's intricate structure and function and the need for precise and targeted drug delivery systems to address prevalent eye conditions. The review categorizes and discusses various formulations employed in ocular drug delivery, delineating their respective advantages and limitations. Additionally, it probes the challenges inherent in diverse routes of drug administration for ocular therapies and provides insights into the complexities of achieving optimal drug concentrations at the target site within the eye. The central theme of this work is the ocular compartmental modelling and simulations. Hence, this works discusses on the nuanced understanding of physiological conditions within the eye, drug distribution, drug release kinetics, and key considerations for ocular compartmental modelling and simulations. By combining information from various sources, this review aims to serve as a comprehensive reference for researchers, clinicians, and pharmaceutical developers. It covers the multifaceted landscape of ocular biopharmaceutics and the transformative impact of modelling and simulation in optimizing ocular drug delivery strategies.

Treatment outcomes in retinoblastoma and the effect of tumor topography

BACKGROUND

Retinoblastoma, the most common intraocular malignancy in children, has high fatality rates if untreated. It is crucial to monitor treatment effectiveness and explore factors influencing favorable outcomes. Our study aims to examine how tumor location impacts the response to standard treatments and the achievement of favorable outcomes among retinoblastoma patients, while controlling for other tumor-related factors.

METHODS

This retrospective study analyzed medical records of retinoblastoma patients from November 2012 to December 2022 enrolled in the retinoblastoma program at the Children's Cancer Center of Lebanon (established in collaboration with St.y Jude Children's Research Hospital, Memphis, TN). Data were extracted from the electronic chart reviews and operative reports of examinations under anesthesia (EUAs), and included patient's demographics, tumor characteristics (size, location), and treatment parameters (treatment type, resolution, recurrence).

RESULTS

The study included 42 patients with retinoblastoma, with a total of 57 eyes and 115 tumors/lesions. The median age at diagnosis was 12 months (range: 2-36 months). Among the patients, 26 (61.9%) were males and 16 (38.1%) were females. A minority of patients (21.4%) presented with unilateral involvement, whereas the majority (78.6%) had bilateral involvement. The locations of retinoblastoma lesions were distributed as follows: optic nerve (4.4%), macula (19.1%), superior (16.5%), inferior (17.4%), nasal (27.8%), and temporal (14.8%). Resolution rate tended to be highest for tumors close to optic nerve and temporal lesions, but no statistical significance was attained (p = .45). Macular lesions tended to have the fastest resolution, but again not significantly (p = .5). Multiple logistic regression revealed that the odds for resolution of tumor was not significantly associated with tumor size (p = .57) or location (p = .52).

CONCLUSION

Location of retinoblastoma lesions was not directly associated with recurrence-free resolution in our cohort. Further research in large retinoblastoma databases is needed to explore the association of tumor characteristics with recurrence and the need for secondary therapeutic interventions.

Intraocular Surgery for Retinoblastoma: An Evaluation of Current Evidence

Background

Retinoblastoma (Rb) is the most common intraocular malignancy of childhood. The prognosis in Rb directly relates to the spread of disease beyond the eye, particularly to the central nervous system. Therefore, until the recent past, surgically entering an eye with active or recently active Rb was absolutely contraindicated in most centres around the world due to the risk of iatrogenic extraocular spread.

Summary

In this review article, we explore the role of intraocular surgery in Rb. We describe the techniques which have been developed in order to safely deliver chemotherapeutic agents into the eye, both intravitreal and intracameral. We discuss the role of vitrectomy and endoresection for treatment of vitreous seeds and active retinal tumours. In the context of previously treated Rb, we outline various surgical interventions performed to improve visual outcomes or to manage the ocular sequelae of the disease. In particular, we review the various techniques used to maximise the safety of cataract, retinal and glaucoma surgery in children with a history of Rb.

Key Messages

The role of intraocular surgery in Rb is now well established, particularly in the delivery of chemotherapeutic agents or in the presence of previously treated diseases. The role of intraocular surgery in eyes with active Rb is less well established and remains the subject of much debate. However, it is likely that with further development of safer surgical techniques, the indications and modalities will continue to broaden.

Intravitreal Melphalan versus Topotecan for Vitreous Seeds in Retinoblastoma: A Comparative Study of 64 Asian Indian Eyes

PURPOSE

To compare the outcomes of intravitreal melphalan (IVit-M) versus intravitreal topotecan (IVit-T) for vitreous seeds (VS) in retinoblastoma (RB).

DESIGN

Retrospective interventional study.

PARTICIPANTS

Patients of RB with VS receiving intravitreal chemotherapy (IVit-C) between December 2012 and December 2022, at a single quaternary ocular oncology referral center.

INTERVENTION

Intravitreal melphalan injection of 25 μg/0.1 mL in 25 eyes and IVit-T of 30 μg/0.15 mL in 39 eyes.

MAIN OUTCOME MEASURES

Resolution of VS, globe salvage, IVit-C-related complications.

RESULTS

The mean age at presentation was 28 months (median, 24 months; range, 4-144 months) for the IVit-M group and 25 months (median, 24 months; range, 2-60 months) for the IVit-T group. At the time of initiation of intravitreal injection, the VS belonged to type 1 (1 [4%] vs. 1 [3%]), type 2 (9 [36%] vs. 14 [36%]), type 3 (8 [32%] vs. 18 [46%]), or a combination of these (7 [28%] vs. 6 [15%]) in IVit-M and IVit-T groups, respectively. Complete resolution of VS after IVit-C was seen in 22 (92%) and 28 (72%) eyes (P = 0.069) in IVit-M and IVit-T groups, respectively. At a mean follow-up period of 44 months after the first IVit-C injection in the IVit-M group and 19 months in the IVit-T group, globe salvage was higher in the IVit-T group (77%) than in the IVit-M group (60%, P = 0.148), respectively. Posterior segment complications were significantly higher in the IVit-M group than in the IVit-T group (P < 0.001). These included retinal pigment epithelial atrophy (P < 0.001), optic atrophy (P < 0.001), vascular attenuation (P < 0.001), and retinal/subretinal hemorrhages (P = 0.004).

CONCLUSIONS

Intravitreal topotecan is as efficacious as IVit-M for controlling VS in RB, with a better safety profile in pigmented Asian Indian eyes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Prospects of anti-GD2 immunotherapy for retinoblastoma

Retinoblastoma is the most common type of eye tumor in infants and children. Current treatments for retinoblastoma include intravenous chemotherapy, intra-arterial chemotherapy, intravitreal chemotherapy, cryotherapy, radiotherapy, and surgery. However, these treatments come accompanied by adverse effects such as the toxic side effects of chemotherapeutic drugs, post-operative complications including blindness after surgery, or other complications caused by radiotherapy. Immunotherapy is more promising for its low toxicity on normal cells and effectively improves the quality of life of patients. Disialoganglioside (GD2), a sphingolipid expressed on the surface of retinoblastoma, is a potential therapeutic target for retinoblastoma. We summarized immunotherapeutic approaches for both preclinical studies and clinical trials of GD2. An anti-GD2 monoclonal antibody (Dinutuximab), which has been approved for the treatment of high-risk neuroblastomas, has shown promising efficacy in improving patients' prognosis. Additionally, chimeric antigen receptors (CAR)-T therapy, GD2 vaccines and nanoparticles are also potential therapeutics. Finally, we discuss the prospects and current limitations of these immunotherapeutic approaches for treating retinoblastoma, as well as how to address these problems.

Worldwide Burden of Retinoblastoma from 1990 to 2021

INTRODUCTION

The aim of the study was to report the global, regional, and national burden of retinoblastoma between 1990 and 2021, by age, sex, and sociodemographic index (SDI).

METHODS

We leveraged the Global Burden of Disease 2021 Study to elucidate the epidemiological landscape of retinoblastoma, encompassing prevalence, incidence, mortality, and disability-adjusted life years (DALYs) across 204 nations and territories spanning the period from 1990 to 2021. The SDI was employed to evaluate the interplay between socioeconomic development and the burden of retinoblastoma.

RESULTS

In 2021, global estimates unveiled 57,333 prevalent cases of retinoblastoma, yielding 6,274 incident cases, 2,762 deaths, and 243,204 DALYs. Globally, the age-standardized prevalence, incidence, mortality, and DALY rates for retinoblastoma in 2021 were 0.86, 0.09, 0.04, and 3.65 per 100,000 population, respectively. Tokelau, Kenya, and Portugal demonstrated the highest age-standardized prevalence and incidence rates of retinoblastoma in 2021. The global prevalence of retinoblastoma peaks among children aged 2-4 years and subsequently declines with increasing age. At the regional level, the correlation between SDI and age-standardized prevalence rates for retinoblastoma manifested a V-shaped pattern.

CONCLUSIONS

This comprehensive examination of retinoblastoma epidemiological trends underscores the imperative for heightened vigilance and more efficacious therapeutic interventions, especially within resource-limited environments. The findings accentuate the need for targeted strategies to address the disparate burden of retinoblastoma across diverse socioeconomic landscapes.

Disparities in United States Retinoblastoma Presentation, Management, and Local Recurrence in the National Cancer Database, 2004-2016

PURPOSE

To investigate patient-level differences in retinoblastoma presentation, treatments, and outcomes within the United States (US).

DESIGN

Retrospective registry-based analysis.

PARTICIPANTS

One thousand, four hundred and four retinoblastoma cases in the National Cancer Database, 2004-2016, a US-based cancer registry.

METHODS

Patient characteristics and treatments were investigated over time. Primary treatment was classified as enucleation, local tumor destruction, chemotherapy, and radiation. Multivariable logistic regression models evaluated extraocular disease at presentation, treatment, and local recurrence after primary globe-sparing therapy.

MAIN OUTCOME MEASURES

Odds ratios (ORs) for extraocular disease at presentation; primary treatment modality; local recurrence after primary globe-sparing therapy.

RESULTS

Extraocular disease affected 13% of patients at presentation (N = 178). All-cause mortality among the entire cohort was 3.1% (n = 44) at last follow-up Those who were non-White, who were uninsured or had government-funded insurance, or with nonmetropolitan residence had significantly greater odds of extraocular disease (OR 2.21-3.64 for non-White vs. White non-Hispanic patients, OR 2.05-2.95 for uninsured or Medicaid/Medicare/government-funded vs. private/commercial insurance, and OR 1.80 for nonmetropolitan vs. metropolitan residence). Between 2004 and 2016, utilization of chemotherapy (55%-73%) and local tumor destruction (17%-27%) increased. Enucleations remained overrepresented among Hispanic patients (63% received enucleation in 2016, vs. 35% non-Hispanic patients; OR = 1.83 (95% confidence interval [CI] 1.22-2.75) for enucleation among Hispanic vs. White, non-Hispanic patients). Patients with Medicaid/Medicare/government insurance and nonmetropolitan residents also had higher odds of enucleation, and nonmetropolitan patients had higher odds of local recurrence after primary globe-sparing therapy.

CONCLUSIONS

Despite an overall decline in enucleation and increase in globe-sparing therapy between 2004 and 2016, Hispanic, Medicaid/Medicare/government-insured, and nonmetropolitan patients continued to have higher odds of extraocular disease at presentation and higher odds of undergoing enucleation as primary therapy. This suggests limitations in access to care and that shifts toward globe-sparing treatment (chemotherapy and local tumor destruction) did not occur equally across all patient groups. Further investigations into these disparities are warranted.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A comprehensive genotype-phenotype study in 203 individuals with retinoblastoma

Retinoblastoma is the most common intraocular tumor in children and is caused by biallelic inactivation of the RB1 gene. The identification of RB1 germline variants in patients with retinoblastoma and their families is critical for early diagnosis and prevention. In this study, genetic testing was conducted on the genomic DNA of 203 patients with retinoblastoma using a combined approach of direct sequencing and multiplex ligation-dependent probe amplification (MLPA) assays for genotype-phenotype correlation studies. Sixty-five germline variants were identified in 80 of the 203 patients, with 67 bilateral and 13 unilateral retinoblastoma cases. The variant detection rates in the bilateral and unilateral cases were 88% and 10%, respectively. Eighteen novel variants were identified. Variants were classified according to their presence, mutation pattern, location, molecular consequences, and pathogenicity. Subsequently, the genotypes and phenotypes of the 203 patients were evaluated. Variants were associated with age at diagnosis (p < 0.001), laterality (p < 0.001), and tumor size (p = 0.010). The molecular consequences of the variants were related to laterality (p < 0.001) and tumor size (p = 0.001). The pathogenicity of the variants was associated with age at diagnosis (p = 0.001), laterality (p = 0.0212), treatment response (p = 0.0470), and tumor size (p = 0.002). These results suggest that patient phenotypes are associated with the inherent characteristics of germline RB1 variants. These findings indicate the potential application of genetic testing results in clinical practice.

USP14 increases the sensitivity of retinoblastoma to cisplatin by mediating the ferroptosis

The aim of this study is to explore the function of USP14 on the sensitivity of retinoblastoma (RB) to cisplatin (DDP) and the underlying mechanism. USP14 was knockdown in Y79 cells by transfecting three siRNAs (si-USP14-1, si-USP14-2, and si-USP14-3), with si-USP14 NC as the negative control. si-USP14-3 was selected by results of Western blotting. The CCK-8 assay was used to detect the IC50 of Y79 cells and the growth curve. The cell cycle, cell apoptosis, and ROS level were measured by flow cytometry. The expression level of P-GP, ERCC1, survivin, GPX4, FTH1, ACSL4, NOX1, COX2, and FASN was determined by the Western blotting assay. CO-IP assay was utilized to evaluate the interaction between USP14 and FASN. The IC50 of DDP in Y79 cells and Y79/DDP cells was 7.83 µM and 24.67 µM, respectively. Compared to control and si-USP14 NC groups, increased apoptotic rate and ROS level, and arrested cell cycle in S phase were observed in USP14-knockdown Y79 cells. Compared to control and si-USP14 NC groups, increased apoptotic rate and arrested cell cycle in G0/G1 phase were observed in USP14-knockdown Y79/DDP cells. Compared to control, increased ROS level was observed in USP14-knockdown Y79/DDP cells. Compared to the si-USP14 NC groups, extremely downregulated P-GP, ERCC1, survivin, GPX4, FTH1, NOX1, COX2, and FASN were observed in USP14-knockdown Y79 cells or Y79/DDP cells, accompanied by the elevated expression of ACSL4. The interaction between USP14 and FASN was identified according to the result of CO-IP assay. By silencing USP14 in Y79 and Y79/DDP cells, levels of resistance-related proteins (P-GP, ERCC1, and survivin), ferroptosis-related proteins (FTH1 and GPX4), and lipid metabolism-related proteins (NOX1, COX2, and FASN) were dramatically reduced, accompanied by enhanced ROS level, increased apoptosis, and restrained DNA content, indicating that USP14 might suppress the DDP resistance in RB by mediating ferroptosis, which is an important target for treating RB.

Management of Intraocular Retinoblastoma: ICMR Consensus Guidelines

Retinoblastoma (RB) is the most common childhood intraocular malignancy. Delayed presentation due to a lack of awareness and advanced intraocular tumors are a common scenario in low-middle income countries (LMICs). Remarkable treatment advances have been made in the past few decades allowing globe salvage in advanced intraocular RB (IORB) including systemic chemotherapy with focal consolidation and targeted treatments like intraarterial chemotherapy and intravitreal chemotherapy. However, a lack of availability and affordability limits the use of such advances in LMICs. External beam radiotherapy, despite risk of second cancers in RB with germline mutations, still remains useful for recalcitrant RB not responding to any other treatment. When choosing conservative treatment for advanced IORB, the cost and long duration of treatment, morbidity from multiple evaluation under anesthesias (EUAs), side effects of treatment and risk of treatment failure need to be taken into account and discussed with the parents. In this article, the authors discuss the ICMR consensus guidelines on the management of IORB.

Is Intravenous Access Necessary in Pediatric Patients Undergoing Ophthalmologic Examinations Under Anesthesia? A Prospective Observational Study

Purpose

Ophthalmologic examinations under anesthesia (EUA) were employed in pediatric patients due to lower cooperation levels and associated discomfort during comprehensive eye examinations. There remains uncertainty regarding the necessity of intravenous (IV) placement during general anesthesia. The primary aim of the study is to investigate the impact of general anesthesia, with and without IV access, on operation time in pediatric patients undergoing EUA. Secondary objectives include assessing cardiovascular and respiratory complications and measuring parental satisfaction in both the IV and No IV groups.

Patients and Methods

This prospective observational analytic study, conducted as a cross-sectional study, took place between October 2019 and October 2020, in Department of Anesthesiology, Faculty of Medicine, Khon Kaen University, Thailand. We included healthy pediatric patients aged 2 to 7 years undergoing elective ambulatory EUA.

Results

Eighty-two patients, with 41 in the IV group and 41 in the No IV group, were enrolled and included for analysis. The No IV group showed a significantly shorter median operation time (7.99 (6.63, 9.36) minutes) compared to the IV group (10.9 (9.05, 12.28) minutes), with a median difference of -2.74 minutes (95% CI -3.76, -1.69, p < 0.001). In both groups, no cardiovascular or respiratory complications occurred, and there was no need for emergency IV access or drug administration. Children without IV access had higher parental satisfaction in extreme satisfaction (100% vs 48.78%; p < 0.001).

Conclusion

Providing general anesthesia for EUA without IV access in healthy pediatric patients, leading to shorter operation times and heightened parental satisfaction, can be conducted safely.

Clinical Trial Registration Number

The trial registration number is TCTR20191021001 from the Thai Clinical Trials Registry.

Pineal gland ADC values in children aged 0 to 4 years: normative data and usefulness in the differential diagnosis with trilateral retinoblastoma

PURPOSE

Normative ADC values of the pineal gland in young children are currently lacking, however, these are potentially useful in the differential diagnosis of pineal involvement in trilateral retinoblastoma, which is challenging when the size of the tumor is less than 10-15 mm. The main objective of this study was to establish ADC reference values of the normal pineal gland in a large cohort of children between 0 and 4 years.

METHODS

This retrospective study was conducted in a tertiary pediatric hospital. We collected 64 patients with normal MRI examination (between 2017 and 2024) and clinical indication unrelated to the pineal gland, and divided them into 5 age groups (0 to 4 years). Gland size and mean ADC values were calculated, using the ellipsoid formula and ROI/histogram analysis, respectively. The established values were tested in three cases of trilateral retinoblastoma (10 to 20 months).

RESULTS

Mean ADC values were always above 1000 × 10- 6 mm2/s, while in patients with trilateral retinoblastoma they were around 800 × 10- 6 mm2/s. Pineal ADC values were identical in both genders. The volume of the pineal gland showed a tendency to increase with age.

CONCLUSIONS

We present ADC reference data for the pineal gland in children under 4 years of age. The distribution of mean ADC values of trilateral retinoblastoma was significantly different from the normative values, hence, the use DWI/ADC may help to identify small trilateral retinoblastoma in children with ocular pathology.

Advancements in the diagnosis, prognosis, and treatment of retinoblastoma

Retinoblastoma (RB) is a prevalent primitive intraocular malignancy in children, particularly in those younger than age 3 years. RB is caused by mutations in the RB1 gene. In developing countries, mortality rates for this type of cancer are still high, whereas industrialized countries have achieved a survival rate of >95%-98%. Untreated, the condition can be fatal, underscoring the importance of early diagnosis. The existing treatments primarily consist of surgery, radiotherapy, and chemotherapy. The detrimental effects of radiation and chemotherapeutic drugs have been documented as factors that contribute to increased mortality rates and negatively affect the quality of life for patients. MicroRNA (miRNA), a type of noncoding RNA, exerts a substantial influence on RB development and the emergence of treatment resistance by regulating diverse cellular processes. This review highlights recent developments in the involvement of miRNAs in RB. This encompasses the clinical significance of miRNAs in the diagnosis, prognosis, and treatment of RB. Additionally, this paper examines the regulatory mechanisms of miRNAs in RB and explores potential therapeutic interventions. This paper provides an overview of the current and emerging treatment options for RB, focusing on recent studies investigating the application of different types of nanoparticles for the diagnosis and treatment of this condition.

[Enucleations, eviscerations and orbital implants in German eye hospitals]

BACKGROUND

Evaluation of the number of enucleations and eviscerations performed in Germany and the orbital implants used.

METHOD

Analysis of the quality reports of German ophthalmological clinics for the years 2012-2021 provided by the Federal Joint Committee (Gemeinsamer Bundesausschuss, G‑BA).

RESULTS

Almost 10 times as many enucleations (8368) as eviscerations (975) are performed in Germany. After enucleation, alloplastic implants are used most frequently (44.6% alloplastic, no further specification, 30.0% alloplastic coated, no further specification; 14.1% microporous implants) and autologous dermis-fat grafts in 6.1% of the cases.

CONCLUSION

In Germany, significantly more enucleations than eviscerations are performed. Alloplastic orbital implants are preferred for primary reconstruction following enucleation.

Assessing the Metabolic Variations of Invasive and Noninvasive Unilateral Retinoblastoma Patients

Retinoblastoma (Rb) is a pediatric eye cancer which if diagnosed at later stages can lead to Rb invasion into the choroid, optic nerve, sclera, or beyond, with the potential of undergoing metastasis. Cancer cells, including Rb cells, reprogram their metabolic circuits for their own survival and progression, which provides a great opportunity to monitor the extent of Rb progression based on metabolic differences. Henceforth, the present study aims to map the metabolic variations in patients with invasive (primarily enucleated eyes with high-risk histopathological features) and noninvasive (eyes salvaged with treatment) unilateral retinoblastoma (Rb) using nuclear magnetic resonance (NMR) based serum metabolomics. Quantification of differential metabolites in the serum obtained from 9 patients with invasive and 4 with noninvasive unilateral Rb along with 6 controls (no retinal pathology) was carried out using 1H NMR spectroscopy. A total of 71 metabolites, such as organic acids, amino acids, carbohydrates, and others, were identified in the serum obtained from 9 patients with invasive and 4 with noninvasive unilateral Rb. Partial least-squares discriminant analysis (PLS-DA) models depicted distinct grouping of invasive and noninvasive Rb patients and controls. Differential metabolic fingerprints were observed for invasive and noninvasive Rb patients based on their biostatistical analyses with respect to controls. Remarkable perturbation was observed among various metabolites such as 4-aminobutyrate, 2-phosphoglycerate, O-phosphocholine, proline, Sn-glycero-3-phosphocholine (Sn-GPC), and O-phosphoethanolamine in noninvasive and invasive Rb patients with most of the effects being heightened in the latter group. Metabolic changes unique to invasive and noninvasive Rb patients were also observed. Multivariate receiver operating characteristics (ROC) analysis unveiled the highest accuracy and potency of ROC models 2 and 5 to distinguish the noninvasive and invasive Rb from controls, respectively. Metabolites identified in the serum of patients with invasive and noninvasive Rb may aid in advancing our knowledge about Rb tumor biology. Differential aberrant metabolic variations in patients with invasive Rb compared to those with noninvasive Rb may guide the decision of enucleation versus globe salvage.

Investigating druggable kinases for targeted therapy in retinoblastoma

Retinoblastoma (RB) is a childhood retinal neoplasm and commonly treated with cytotoxic chemotherapeutic agents. However, these therapeutic approaches often lead to diverse adverse effects. A precise molecular therapy will alleviate these side effects and offer better treatment outcomes. Over the years, kinases have become potential drug targets in cancer therapy. Hence, we aimed to investigate genetic alterations of putative kinase drug targets in RB. Targeted exome sequencing was performed on 35 RB tumors with paired blood samples using a gene panel consisting of 29 FDA-approved kinase genes. Single nucleotide variants were analyzed for pathogenicity using an in-house pipeline and copy number variations (CNVs) were detected by a depth of coverage and CNVPanelizer. The correlation between genetic changes and clinicopathological features was assessed using GraphPad Prism. Three somatic mutations, two in ERBB4 and one in EGFR were identified. Two of these mutations (ERBB4 c.C3836A & EGFR c.A1196T) were not reported earlier. CNV analysis revealed recurrent gains of ALK, MAP2K2, SRC, STK11, and FGFR3 as well as frequent losses of ATM, PI3KCA and ERBB4. Notably, nonresponsive tumors had a higher incidence of amplifications in clinically actionable genes such as ALK. Moreover, ALK gain and ATM loss were strongly correlated with optic nerve head invasion. In conclusion, our study revealed genetic alterations of druggable kinases in RB, providing preliminary insights for the exploration of kinase-targeted therapy in RB.

CTSB Nuclear Translocation Facilitates DNA Damage and Lysosomal Stress to Promote Retinoblastoma Cell Death

Retinoblastoma (RB) is a pernicious tumor originating from photoreceptor precursor cells that often endangers the lives of children. The purpose of our study was to further investigate the influence of cathepsin B (CTSB) nuclear translocation on RB cell death. Y79 cells were injected into the vitreous cavity of nude mice at a dose of 4 µL/mouse to establish an animal model of RB. Real-time quantitative polymerase chain reaction (RT-qPCR), Western blot analysis, a comet assay, a Cell Counting Kit-8 (CCK-8) assay and flow cytometry were used to measure the levels of the interrelated genes and proteins and to evaluate alterations in autophagy, apoptosis, proliferation, DNA damage and cell cycle arrest. CTSB was found to be expressed at low levels in RB animal model samples and RB cell lines. Functionally, CTSB nuclear translocation promoted DNA damage, cell cycle arrest, ferroptosis and autophagy in Y79 cells and inhibited their proliferation. Downstream mechanistic studies showed that nuclear translocation of CTSB facilitates DNA damage and cell cycle arrest in RB cells by inhibiting breast cancer 1 protein (BRCA1) expression and also activates the signal transducer and activator of transcription 3/stimulator of interferon response cGAMP interactor 1 (STAT3/STING1) pathway to induce lysosomal stress, leading to ferroptosis and autophagy in Y79 cells and alleviating RB. Nuclear translocation of CTSB facilitates DNA damage and cell cycle arrest in RB cells by inhibiting BRCA1 expression and activating the STAT3/STING1 pathway and induces lysosomal stress, which eventually leads to ferroptosis and autophagy and mitigates RB.

Targeting GPC2 on Intraocular and CNS Metastatic Retinoblastomas with Local and Systemic Delivery of CAR T Cells

PURPOSE

Retinoblastoma is the most common intraocular malignancy in children. Although new chemotherapeutic approaches have improved ocular salvage rates, novel therapies are required for patients with refractory intraocular and metastatic disease. Chimeric antigen receptor (CAR) T cells targeting glypican-2 (GPC2) are a potential new therapeutic strategy.

EXPERIMENTAL DESIGN

GPC2 expression and its regulation by the E2F1 transcription factor were studied in retinoblastoma patient samples and cellular models. In vitro, we performed functional studies comparing GPC2 CAR T cells with different costimulatory domains (4-1BB and CD28). In vivo, the efficacy of local and systemic administration of GPC2 CAR T cells was evaluated in intraocular and leptomeningeal human retinoblastoma xenograft models.

RESULTS

Retinoblastoma tumors, but not healthy retinal tissues, expressed cell surface GPC2, and this tumor-specific expression was driven by E2F1. GPC2-directed CARs with 4-1BB costimulation (GPC2.BBz) were superior to CARs with CD28 stimulatory domains (GPC2.28z), efficiently inducing retinoblastoma cell cytotoxicity and enhancing T-cell proliferation and polyfunctionality. In vivo, GPC2.BBz CARs had enhanced persistence, which led to significant tumor regression compared with either control CD19 or GPC2.28z CARs. In intraocular models, GPC2.BBz CAR T cells efficiently trafficked to tumor-bearing eyes after intravitreal or systemic infusions, significantly prolonging ocular survival. In central nervous system (CNS) retinoblastoma models, intraventricular or systemically administered GPC2.BBz CAR T cells were activated in retinoblastoma-involved CNS tissues, resulting in robust tumor regression with substantially extended overall mouse survival.

CONCLUSIONS

GPC2-directed CAR T cells are effective against intraocular and CNS metastatic retinoblastomas.

Safety of intravitreal chemotherapy in the management of retinoblastoma: A systematic review of the literature

Intravitreal chemotherapy is used as a salvage therapy for retinoblastoma with persistent or recurrent vitreous seeding after primary treatment. To assess the safety of this technique, we conducted a systematic review of all studies reporting ocular toxicity data. Forty-eight trials involving 2751 eyes were included. The most common complications were cataract, retinal toxicity, and vitreous hemorrhage. However, severe and permanent adverse events were limited, while the risk of extraocular dissemination, a significant concern, was practically eliminated through preventive techniques. Globe salvage rates ranged from 29 % to 100 %. In conclusion, intravitreal chemotherapy seems to improve prognosis of eyes with advanced disease, with an acceptable safety profile. Nevertheless, most relevant studies are retrospective, and no randomized trials have been performed. Recognizing the challenges regarding the conduct of randomized studies for such a rare pediatric cancer, we believe that multicenter trials through international collaborations can significantly enhance the available information.

Personalized treatment approaches in intraocular cancer

Background

Intraocular malignant tumors represent a severe disease that threatens vision as well as life. To better extend the life of the patient, preserve visual function, and maintain ocular aesthetics, selecting the appropriate timing and methods of treatment becomes crucial.

Main text

With the continuous advancement of medical technology, the techniques and methods for treating intraocular malignant tumors are constantly evolving. While surgery was once considered the optimal method to prolong patient survival and prevent local recurrence, the discovery and application of various treatments such as radiotherapy, laser therapy, chemotherapy, cryotherapy, and monoclonal antibodies have led to a greater diversity of treatment options. This diversity offers more possibilities to develop personalized treatment plans, and thereby maximize patient benefit. This article reviews the various treatment methods for intraocular malignant tumors, including indications for treatment, outcomes, and potential complications.

Conclusions

Differentiating small intraocular malignant tumors from pigmented lesions is challenging, and ongoing monitoring with regular follow-up is required. Small to medium-sized tumors can be treated with radiotherapy combined with transpupillary thermotherapy. Depending on the tumor's distance from the optic disc, surgery with partial resection may be considered for distant tumors, while proximal tumors may require complete enucleation. Systemic chemotherapy has been widely applied to patients with retinal tumors, lymphomas, and intraocular metastatic cancers, but has limited efficacy in patients with choroidal melanoma. Antagonists of Vascular Endothelial Growth Factor (Anti-VEGF) drugs can improve patient vision and quality of life, while the efficacy of immunotherapy and molecular targeted therapy is still under research.

A comprehensive review on lncRNA LOXL1-AS1: molecular mechanistic pathways of lncRNA LOXL1-AS1 in tumorigenicity of cancer cells

Long non-coding RNAs (lncRNAs) are versatile RNAs that regulate various cellular processes, such as gene regulation, by acting as signals, decoys, guides, and scaffolds. A novel recognized lncRNA, LOXL1-antisense RNA 1 (LOXL1-AS1), is dysregulated in some diseases, including cancer, and acts as an oncogenic lncRNA in many types of cancer cells. Upregulation of LOXL1-AS1 has been involved in proliferation, migration, metastasis, and EMT, as well as inhibiting apoptosis in cancer cells. Most importantly, the malignant promoting activity of LOXL1-AS1 can be mostly mediated by sequestering specific miRNAs and inhibiting their binding to the 3´UTR of their target mRNAs, thereby indirectly regulating gene expression. Additionally, LOXL1-AS1 can decoy transcription factors and proteins and prevent their binding to their regulatory regions, inhibiting their mechanistic activity on the regulation of gene expression and signaling pathways. This review presents the mechanistic pathways of the oncogenic role of LOXL1-AS1 by modulating its target miRNAs and proteins in various cancer cells. Having information about the molecular mechanisms regulated by LOXL1-AS1 in cancer cells can open ways to find out particular prognostic biomarkers, as well as discover novel therapeutic approaches for different types of cancer.

A retrospective study on adjuvant chemotherapy in retinoblastoma: validation of the new recommendation against treatment for pT2a tumors based on the 8th AJCC classification

BACKGROUND

Retinoblastoma (RB) is an intraocular malignant tumor detected in early childhood with variable global impact. Histopathological classification of the tumor in enucleated globes with RB is the key for the decision of adjuvant chemotherapy use. We aim to validate the use of adjuvant chemotherapy in cases with combined pre-laminar/intralaminar optic nerve (ON) invasion and focal choroidal invasion according to the American Joint Committee on Cancer (AJCC) 8th classification.

METHODS

This is a retrospective study conducted at King Abdulaziz University Hospital (KAUH) and King Khalid Eye Specialist Hospital (KKESH) in Riyadh, Saudi Arabia of all RB cases who underwent enucleation over 22 years (2000 to 2021). The histopathological findings were reviewed to identify the enucleated globes classified as pT2a tumors, as an inclusion criterion. Basic demographic and clinical data were collected via chart review Simple descriptive and basic statistical analysis of the data was used where applicable.

RESULTS

Thirty-one patients who had an enucleated globe with RB that fit into the above classification were included. Sixteen were males and 15 were females. The median age was 14 months (IQR = 14 months). Most of the patients (93.5%) had no family history of RB. The commonest presentation was leukocoria in 87.1% followed by squint in 32.3%. Fourteen patients (45.2%) were treated by enucleation alone while 17 patients (54.8%) received adjuvant chemotherapy. Out of these, 7 patients had unilateral RB and the remaining 10 patients had bilateral RB. None of our patients developed recurrence or metastatic disease irrespective of the indication for adjuvant chemotherapy use after a maximum period of follow up reaching 17.84 years and a median of 10.6 years (IQR = 5.92).

CONCLUSIONS

In patients with 8th AJCC histopathological classification of pT2a, chemotherapy following enucleation might not be justified. The outcome in our untreated group of patients did not differ from the treated group with the absence of metastasis after a relatively long period of follow up with a median exceeding 10 years in both groups. Therefore, the risk and benefit of post enucleation adjuvant chemotherapy in the treatment of unilateral RB should be carefully decided and discussed with the primary caregivers taking into consideration the most recent evidence and recommendations in the literature.

Aqueous Humor Liquid Biopsy as a Companion Diagnostic for Retinoblastoma: Implications for Diagnosis, Prognosis, and Therapeutic Options: Five Years of Progress

PURPOSE

To define the prospective use of the aqueous humor (AH) as a molecular diagnostic and prognostic liquid biopsy for retinoblastoma (RB).

METHODS

This is a prospective, observational study wherein an AH liquid biopsy is performed at diagnosis and longitudinally through therapy for patients with RB. Tumor-derived cell-free DNA is isolated and sequenced for single nucleotide variant analysis of the RB1 gene and detection of somatic copy number alterations (SCNAs). The SCNAs are used to determine tumor fraction (TFx). Specific SCNAs, including 6p gain and focal MycN gain, along with TFx, are prospectively correlated with intraocular tumor relapse, response to therapy, and globe salvage.

RESULTS

A total of 26 eyes of 21 patients were included with AH taken at diagnosis. Successful ocular salvage was achieved in 19 of 26 (73.1%) eyes. Mutational analysis of 26 AH samples identified 23 pathogenic RB1 variants and 2 focal RB1 deletions; variant allele fraction ranged from 30.5% to 100% (median 93.2%). At diagnosis, SCNAs were detectable in 17 of 26 (65.4%) AH samples. Eyes with 6p gain and/or focal MycN gain had significantly greater odds of poor therapeutic outcomes (odds ratio = 6.75, 95% CI = 1.06-42.84, P = .04). Higher AH TFx was observed in eyes with vitreal progression (TFx = 46.0% ± 40.4) than regression (22.0 ± 29.1; difference: -24.0; P = .049).

CONCLUSIONS

Establishing an AH liquid biopsy for RB is aimed at addressing (1) our inability to biopsy tumor tissue and (2) the lack of molecular biomarkers for intraocular prognosis. Current management decisions for RB are made based solely on clinical features without objective molecular testing. This prognostic study shows great promise for using AH as a companion diagnostic. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Selective ophthalmic arterial injection using a balloon catheter for retinoblastoma: a seven-year clinical evaluation

PURPOSE

To evaluate the effectiveness and safety of selective ophthalmic arterial injection (SOAI) for retinoblastoma utilizing a microballoon catheter system with an M chamber.

STUDY DESIGN

Retrospective analysis.

METHODS AND PATIENTS

This study was sanctioned by theNational Cancer Center Hospital' Independent Ethics Committee. The surgeon was a general interventional radiologist. After confirming that the distal internal carotid artery was not delineated by balloon occlusion and the ophthalmic artery was visualized using digital subtraction angiography, melphalan was manually administered. Notably, in cases presenting bilateral retinoblastoma, both eyes received treatment in a singular, low-dose procedure. Between July 2015 and December 2021, 125 patients with retinoblastoma (68 boys and 57 girls) underwent SOAI at our facility. The average age at initial treatment was 19.3 months. The study covered 250 procedures, with patients undergoing an average of 3.7 procedures.

RESULTS

The success rate of the procedure was 99.2%, with a mean procedure duration of 18.3 min. Two distinct technical failures were recorded: one attributed to an internal carotid artery having a wide lumen and the other due to the ophthalmic artery remaining undetected on angiography post-balloon occlusion of the internal carotid artery. Adverse events were minimal but included bronchospasm post-procedure and severe orbital inflammation in 0.8% and 0.4% of cases, respectively.

CONCLUSION

SOAI using the microballoon catheter with the M chamber is a feasible and safe procedure for the treatment of retinoblastoma. The success rate was 99.2%. This system can be recommended as intra-arterial chemotherapy for retinoblastoma.

Orbital Development in Children with Retinoblastoma: An Imaging-Based Study

PURPOSE

To examine whether children treated for Retinoblastoma (Rb) have impaired orbital development.

METHODS

A retrospective case series was performed among children with Rb treated at a single medical center from 2004 to 2020. Orbital volumes and measurements were assessed by 3-dimensional image processing software. The main outcome measures were differences in orbital growth between Rb and non-Rb eyes assessed at last follow-up.

RESULTS

Among 44 patients included (mean age 16.09 ± 18.01 months), a positive correlation between age and orbital volume was observed only in the uninvolved, healthy eyes (p = .03). In unilateral cases, orbital growth in the horizontal, vertical, and depth planes was smaller on the affected side compared to the healthy eyes (p < .05). Orbits that underwent enucleation showed decreased growth over time compared to those treated conservatively (p = .017).

CONCLUSIONS

Orbital growth rate is slower in the orbits of children treated for Rb compared to healthy orbits. Enucleation negatively affects orbital growth.

Interventional oncology in children: Where are we now?

Paediatric Interventional Oncology (IO) lags behind adult IO due to a scarcity of specific outcome data. The suboptimal way to evolve this field is relying heavily on adult experiences. The distinct tumour types prevalent in children, such as extracranial germ cell tumours, sarcomas, and neuroblastoma, differ strongly from those found in adults, presenting a completely different biological behaviour. Compounding this challenge, paediatric interventional radiology often employs adapted or off-label techniques, potentially compromising optimal outcomes. This review outlines the present indications for interventional radiology in paediatric cancer, from biopsy to supportive care, including complication management. It emphasises the role of locoregional approaches, and explores the status of common paediatric oncological diseases, highlighting areas where IO has made progress identifying potential opportunities for future advancements in this evolving field.

Retinoblastoma - A comprehensive review, update and recent advances

Retinoblastoma is the most common pediatric ocular malignancy. It is triggered by a biallelic mutation in the RB1 gene or MYCN oncogene amplification. Retinoblastomas can be unilateral (60%-70%) or bilateral (30%-40%); bilateral tumors are always heritable and present at an earlier age as compared to unilateral ones (18-24 months vs. 36 months in India). High prevalence rates, delayed presentation, and inaccessibility to healthcare lead to worse outcomes in developing countries. The past few decades have seen a paradigm change in the treatment of retinoblastomas, shifting from enucleation and external beam radiotherapy to less aggressive modalities for eye salvage. Multimodality treatment is now the standard of care and includes intraarterial or intravenous chemotherapy along with focal consolidation therapies such as transpupillary thermotherapy, cryotherapy, and laser photocoagulation. Intravitreal and intracameral chemotherapy can help in controlling intraocular seeds. Advanced extraocular or metastatic tumors still have a poor prognosis. Genetic testing, counseling, and screening of at-risk family members must be incorporated as essential parts of management. A better understanding of the genetics and molecular basis of retinoblastoma has opened up the path for potential targeted therapy in the future. Novel recent advances such as liquid biopsy, prenatal diagnosis, prognostic biomarkers, tylectomy, and chemoplaque point to promising future directions.

Updated retinoblastoma incidence and outcome in children in Taiwan from 1980 to 2019: a 40-year nationwide study

BACKGROUND

Retinoblastoma is a potentially fatal disease, and its incidence and mortality varies among different countries and periods.

METHODS

This is a nationwide population-based retrospective study from January 1980 to December 2019 in Taiwan. Patients diagnosed as retinoblastoma were identified from the Taiwan National Cancer Registry. To update the literature on retinoblastoma incidence, mortality and trends in Taiwan, we analysed changes in incidence and survival rates over time according to sex, diagnostic age, laterality and treatment.

RESULTS

During 1980-2019, the incidence of retinoblastoma in Taiwan was 1 per 16 489 live births (95% CI: 13 415-19 564). The diagnostic age decreased from 2.21 ± 0.26 during 1980-1984 to 1.24 ± 0.26 during 1985-2019. Compared with that observed during 1980-1989, the incidence rate observed after 1990 increased significantly in children aged <10 years (RR: 1.62-2.40, P = 0.0049 to < 0.0001). From 1980 to 2019, the incidence rate for the 0-4-year age group increased and that for the 5-9-year age group remained constant. The mean diagnostic age for bilateral retinoblastoma (0.36 ± 0.47 years) was significantly less than that for unilateral retinoblastoma (1.37 ± 0.35 years) during 2007-2019 (P < 0.0001). The 10-year survival rate was highest in the enucleation group (89.8%) compared with radiotherapy (52.2%) and others (70.0%; P < 0.0001).

CONCLUSIONS

During 1980-2019 in Taiwan, the incidence of retinoblastoma increased significantly, and the diagnostic age decreased, which are similar to the ones from other developed countries. However, the survival rate was still lower than that of most developed countries.

Molecular Biological Research on the Pathogenic Mechanism of Retinoblastoma

Retinoblastoma (RB) is the most common intraocular malignant tumor in children, primarily attributed to the bi-allelic loss of the RB1 gene in the developing retina. Despite significant progress in understanding the basic pathogenesis of RB, comprehensively unravelling the intricate network of genetics and epigenetics underlying RB tumorigenesis remains a major challenge. Conventional clinical treatment options are limited, and despite the continuous identification of genetic loci associated with cancer pathogenesis, the development of targeted therapies lags behind. This review focuses on the reported genomic and epigenomic alterations in retinoblastoma, summarizing potential therapeutic targets for RB and providing insights for research into targeted therapies.

Absorbable gelatin compressed sponge (Gelfoam) embolization of distal external carotid artery branches in intra-arterial chemotherapy for retinoblastoma

BACKGROUND

In intra-arterial chemotherapy for retinoblastoma, a backflow from unreachable external carotid artery branches in the ophthalmic artery can be challenging.

OBJECTIVE

To describe a new endovascular technique using Gelfoam pledgets to temporarily occlude distal branches of the external carotid artery to reverse the competitive backflow into the ophthalmic artery in order to perform intra-arterial chemotherapy via the ostium of the ophthalmic artery in selected cases.

METHODS

We queried our prospectively collected database of 327 consecutive patients treated for retinoblastoma by intra-arterial chemotherapy and identified those employing Gelfoam pledgets. We describe this new technique with emphasis on feasibility and safety.

RESULTS

We treated 11 eyes with 14 infusions of intra-arterial chemotherapy using Gelfoam pledgets to occlude the distal branches of the external carotid artery. We report no perioperative complications due to this occlusion technique. At the ophthalmologic follow-up 1 month after the injection of Gelfoam pledgets, all cases showed tumor regression or stable disease. Two injections into the same eye as the rescue intra-arterial chemotherapy infusion resulted in a transient exudative retinal detachment, and one injection in a heavily pretreated case was followed by iris neovascularization and retinal ischemia. None of the pledget injections led to irreversible vision-threatening intraocular complications.

CONCLUSIONS

Intra-arterial chemotherapy in retinoblastoma using Gelfoam to transiently occlude the distal branches of the external carotid artery and reverse the backflow into the ophthalmic artery seems feasible and safe. Larges series will help to confirm the effectiveness of this new technique.

FTO promotes the progression of retinoblastoma through YTHDF2-dependent N6-methyladenosine modification in E2F3

Early treatment of retinoblastoma (RB) has significantly improved clinical outcomes. N6-methyladenosine (m6A) methylation is crucial for cancer progression. Thus, we investigated the role of FTO-dependent demethylation in RB and its underlying mechanisms. The biological behavior of RB cells was analyzed using cell counting kit-8, colony formation analysis, transwell assay, flow cytometry, and western blot analysis. m6A modification was evaluated using methylated RNA immunoprecipitation and dual-luciferase reporter assays, and E2F3 stability was assessed using Actinomycin D. The roles of FTO and E2F3 were also elucidated in vivo. These results indicated that FTO was highly expressed in RB cells with low m6A levels. FTO knockdown inhibited RB cell growth, migration, invasion, and epithelial-mesenchymal transition and arrested the cell cycle at the G0/G1 phase. Mechanistically, FTO interference promoted m6A methylation of E2F3, which was recognized by YTHDF2, thereby reducing mRNA stability. E2F3 overexpression partially rescued the effects of FTO knockdown on biological behavior. Moreover, FTO knockdown reduced tumor weight, tumor volume, ki67 expression, and tumor cell infiltration by mediating E2F3. Taken together, FTO silencing inhibited the malignant processes of RB by suppressing E2F3 in an m6A-YTHD2-dependent manner. These findings suggest that FTO is a novel therapeutic target for RB.

[Interdisciplinary Management of Orbital Diseases]

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

Peripapillary fluid: Obvious and not so obvious!

Intraretinal or subretinal fluid in the peripapillary area can be clinically visualized in conditions such as peripapillary choroidal neovascularization, optic disc pit maculopathy, and optic nerve head tumors and granulomas. Optical coherence tomography (OCT) helps to visualize peripapillary fluid in many other chorioretinal conditions such as peripapillary pachychoroid syndrome, posterior uveitis, central retinal vein occlusion, malignant hypertension, hypotonic maculopathy as well as neuro-ophthalmological conditions such as glaucoma, microcystic macular edema and disc edema due papilledema, non-arteritic anterior ischemic optic neuropathy, neuroretinitis, and diabetic papillopathy. Often, the differential diagnosis of peripapillary fluid is a bit tricky and may lead to misdiagnosis and improper management. We describe a diagnostic algorithm for peripapillary fluid on OCT and outline the salient features and management of these conditions.

The Impact of Tumor Laterality (Unilateral vs. Bilateral) on Presentation and Management Outcome in Patients with Retinoblastoma

Background: This study compares the outcomes of managing retinoblastoma between patients with unilateral and bilateral presentations. Methods: The study, conducted at the King Hussein Cancer Center in Amman, Jordan, retrospectively analyzed cases of retinoblastoma treated between March 2003 and December 2019. Evaluation criteria included clinical features, disease stage, treatment methods, and overall management outcomes. Results: The study comprised 697 eyes from 478 patients with retinoblastoma, with 52% being males. Bilateral disease was observed in 70% of patients, and a family history of retinoblastoma was more prevalent in cases with bilateral disease (20%) compared to those with unilateral disease (4%). Unilateral cases had a median age at diagnosis of 28 months, whereas bilateral cases were diagnosed at a median age of 6 months. Extra-ocular retinoblastoma was detected in 1% of eyes. According to the International Intraocular Retinoblastoma Classification (IIRC), 88% of unilateral cases presented with advanced disease (IIRC group D/E), compared to 46% in bilateral cases. Primary enucleation was performed in 29% of unilateral cases and 16% of bilateral cases (p-value 0.0007). Eye salvage rates were 31% in unilateral cases and 68% in bilateral cases (p-value < 0.0001). At 120 months of follow-up, 5% of patients died from secondary neoplasms or metastases, 81% were alive, and 14% were lost to follow-up. There was no significant difference in metastasis, secondary neoplasms, or mortality between patients with unilateral and bilateral retinoblastoma. Conclusions: This study highlights the nuanced differences in clinical characteristics and outcomes between unilateral and bilateral retinoblastoma, emphasizing the necessity of customized management and early detection strategies. It demonstrates that while bilateral retinoblastoma benefits from earlier detection and has a higher rate of eye salvage, there is no significant difference in metastasis or mortality rates when compared to unilateral cases. The critical roles of primary enucleation in advanced cases, along with effective communication and patient education, are also underscored to improve treatment adherence. Overall, these findings point to the importance of tailored approaches in optimizing outcomes for the diverse patient population affected by retinoblastoma.

LncRNA LOXL1-AS1 promotes proliferation and invasion and inhibits apoptosis in retinoblastoma by regulating the MAPK signaling pathway

Retinoblastoma (RB) is an intraocular malignancy that is most common in children and rare in adults. Addressing novel biomarkers and therapeutic targets for RB to modulate tumor progression has become a challenge. The aim of the present study was to investigate the function of long non-coding RNAs (LncRNAs) LOXL1-AS1 in RB cell proliferation and metastasis. It was found that LOXL1-AS1 was overexpressed in RB tissues and cells. In order to evaluate cell viability and colony formation potential, the knockdown of LOXL1-AS1 has been established. Knockdown of LOXL1-AS1 was also inhibited cells migration and invasion. In addition, the proportion of cells in the G2/M phase of the sh-LOXL1-AS1 group increased significantly, and the proportion of cells in the sh-NC group decreased significantly. In the xenograft model of RB, the tumors in the sh-LOXL1-AS1 group grow slowly compared to the sh-NC group. Western blot analysis revealed that LOXL1-AS1 can regulate the progression of RB cells through MAPK signaling pathway in vitro and in vivo. These results indicated that LncRNA LOXL1-AS1 promotes proliferation, invasion and inhibits apoptosis of retinoblastoma by regulating MAPK signaling pathway, and might be expected to be a novel basis for clinical diagnosis and treatment.

Evidence in Focus: The Sparse Landscape of Randomized Trials on Retinoblastoma Treatment

Background

Retinoblastoma, although rare, is one of the most common intraocular malignancies worldwide. Its prognosis has improved significantly in the past few decades, thanks to modern treatments, like systemic, intra-arterial, and intravitreal chemotherapy. However, regarding survival, there are significant differences between high- and low-income countries, eye salvage is still a challenge worldwide, and treatment-related toxicity needs to be carefully and sufficiently managed.

Summary

To appraise the strength of supporting evidence, we performed a systematic review of randomized controlled trials investigating any therapeutic protocol for retinoblastoma. Four trials with 174 participants (188 eyes) were eligible, all pertaining to different intravenous chemotherapy regimens. Vincristine, etoposide, and carboplatin (VEC) appear superior to a 5-drug combination for stage III retinoblastoma. Moreover, etoposide and carboplatin as neoadjuvant chemotherapy followed by thermochemotherapy seem to offer better local control than vincristine and carboplatin. However, increasing carboplatin dose in the VEC protocol failed to improve treatment efficacy.

Key Messages

Retinoblastoma is a success story of modern medicine. However, only intravenous chemotherapy has been studied through randomized trials, while evidence for the most novel retinoblastoma treatments has mainly stemmed from observational studies. International collaborations for multicenter randomized trials could overcome difficulties and increase certainty and precision in the field.

Advanced Interventional Treatments in Retinoblastoma Management: A Comprehensive Review

Retinoblastoma is the most common eye malignancy in children that if left untreated can invade intraocular structures, metastasize, and rarely lead to death. Traditionally treated with systemic chemotherapy, Intra-arterial chemotherapy is gaining popularity as it allows for the direct administration of chemotherapy through the ophthalmic artery, thus reducing systemic side effects. Intra-arterial chemotherapy procedures have evolved, with refinements to reduce risks and radiation exposure. Intra-arterial chemotherapy boasts an impressive technical success rate and one year ocular survival even amongst advanced cases. This review offers a thorough examination of the technique, indications, contraindications, outcomes, and alternative options for Intra-arterial chemotherapy.

Diagnostic Imaging for Retinoblastoma Cancer Staging: Guide for Providing Essential Insights for Ophthalmologists and Oncologists

Retinoblastoma is the most common cause of all intraocular pediatric malignancies. It is caused by the loss of RB1 tumor suppressor gene function, although some tumors occur due to MYCN oncogene amplification with normal RB1 genes. Nearly half of all retinoblastomas occur due to a hereditary germline RB1 pathogenic variant, most of which manifest with bilateral tumors. This germline RB1 mutation also predisposes to intracranial midline embryonal tumors. Accurate staging of retinoblastoma is crucial in providing optimal vision-, eye-, and life-saving treatment. The AJCC Cancer Staging Manual has undergone significant changes, resulting in a universally accepted system with a multidisciplinary approach for managing retinoblastoma. The authors discuss the role of MRI and other diagnostic imaging techniques in the pretreatment assessment and staging of retinoblastoma. A thorough overview of the prevailing imaging standards and evidence-based perspectives on the benefits and drawbacks of these techniques is provided. Published under a CC BY 4.0 license. Test Your Knowledge questions for this article are available in the supplemental material.

Incidence of second primary cancers in patients with retinoblastoma: a systematic review and meta-analysis

Introduction

This systematic review and meta-analysis aimed to examine the risk of second primary cancers (SPCs) among retinoblastoma (Rb) patients, both hereditary and nonhereditary. Previous studies have reported on the long-term risk of SPCs in these patient populations, but a comprehensive synthesis of the existing evidence is lacking.

Methods

A systematic search was conducted in PubMed, EMBASE, and Cochrane Library from inception to 12 March 2023, supplemented by manual screening. Eligible studies were identified, and data were extracted. The primary outcome measure was the standardized incidence ratios (SIRs) of SPCs in Rb patients. Summary estimates were calculated using random or fixed effects models. The quality of included studies was assessed using the Newcastle-Ottawa Scale.

Results

Ten studies, including nine high-quality studies, were included in this review. The summary estimate of SIR for SPCs among hereditary Rb patients was 17.55 (95% CI=13.10-23.51), while the pooled estimate of SIR for SPCs among nonhereditary Rb patients was 1.36 (95% CI=0.90-2.04). Significant differences in SIRs for different SPC types were observed (P=0.028), including nasal cavity tumor (SIR=591.06, 95% CI=162.79-2146.01), bone tumor (SIR=442.91, 95% CI=191.63-1023.68), soft tissue sarcoma (SIR=202.93, 95% CI=114.10-360.93), CNS (SIR=12.84, 95% CI=8.80-18.74), and female breast cancer (SIR=3.68, 95% CI=2.52-5.37). Chemotherapy and radiation therapy were associated with an increased risk of SPCs among hereditary Rb patients.

Discussion

The findings of this review indicate that hereditary Rb patients have a significantly elevated risk of developing SPCs, whereas nonhereditary Rb patients do not show the same risk. Furthermore, significant differences were observed in the SIRs of different SPC types. Treatment techniques, specifically chemotherapy and radiation therapy, were associated with an increased risk of SPCs among hereditary Rb patients. These findings highlight the importance of radiation protection for Rb patients and the need for further research and tailored management strategies for this high-risk population.

Retinoblastoma Incidence in Taiwan Over a Recent 20-Year Period: A Comprehensive Nationwide Study

Purpose

Continuous advancements in medical diagnostic technology and the growing availability of resources suggest a potential for fluctuations in the incidence rate of retinoblastoma (Rb). This study aimed to analyze incidence data of Rb patients in Taiwan from 1999 to 2018, utilizing the nationwide Taiwan Cancer Registry (TCR) database. Additionally, we investigated the treatment modalities used for these Rb patients and compared them with those observed in other countries.

Patients and Methods

We conducted a retrospective cohort study utilizing data from the TCR database. The study cohort comprised individuals who were newly diagnosed with Rb between 1999 and 2018. The incidence of Rb was calculated as the number of patients with Rb per million live births, both for the entire population and for different gender groups and time periods. The trends in Rb incidence from 1999 to 2018 across various age groups and sexes were presented with the linear trend test.

Results

From 1999 to 2018, a total of 248 cases of Rb were identified. The overall incidence rate over this 20-year period was 60.20 cases per million live births, corresponding to 1 case per 16,611 live births. Incidence rates for each 5-year period between 1999 and 2018 exhibited no significant differences. The study cohort was predominantly male, with 134 cases (54.03%) being males and 114 cases (45.97%) being females, resulting in an overall male-to-female sex ratio of 1.18. Females had lower relative risk than males (RR: 0.92, 95% CI: 0.72-1.19). Primary surgical intervention was the preferred treatment modality for over 75% of the cases.

Conclusion

This retrospective epidemiology study, using TCR from 1999 to 2018, indicated that no discernible trend of retinoblastoma incidence in Taiwan. Nevertheless, continuous monitoring of incidence rates and exploration of treatment strategies for retinoblastoma within the Taiwanese population are important to address potential changes in developing medical practices.

Update on chemotherapy modalities for retinoblastoma: Progress and challenges

Retinoblastoma stands as a paradigm of success in treating malignancies among pediatric patients. Over recent decades, the approach to managing retinoblastoma has evolved significantly, transitioning from the preservation of patients' lives to the preservation of eyes and vision while minimizing treatment-related complications. Chemotherapy, administered through diverse routes, has solidified its role as the cornerstone of retinoblastoma treatment. In addition to intravenous chemotherapy (IVC), alternative administration routes, including intraarterial (IAC), intravitreal, intracameral, and periocular delivery, have emerged as promising modalities for retinoblastoma management. Numerous studies have demonstrated outstanding outcomes, achieving nearly 100% salvage rates for eyes classified under groups A-C. However, for advanced intraocular retinoblastoma (groups D and E eyes), IAC appears to offer superior local control rates compared to IVC. Intravitreal injection of chemotherapeutic agents, when administered in a controlled and secure manner, holds promise in averting the need for enucleation and radiotherapy in advanced retinoblastoma cases presenting with vitreous seeds. The optimal chemotherapy strategy remains meticulously tailored based on numerous factors. This review provides a comprehensive update on chemotherapy across various routes, encompassing key considerations, dosages, administration methods, treatment outcomes, and potential complications. Furthermore, it explores emerging potential treatments and outlines future directions aimed at enhancing treatment outcomes.

Gentiopicroside inhibits retinoblastoma cell proliferation, invasion, and tumorigenesis in nude mice by suppressing the PI3K/AKT pathway

Retinoblastoma is a prevalent pediatric intraocular tumor. The suppressive effect of gentiopicroside (GPS) has been reported on various tumors. This study sought to determine the effect of GPS on retinoblastoma cell proliferation, apoptosis, invasion, and epithelial-mesenchymal transition (EMT), and tumorigenesis in nude mice. The effect and mechanism of GPS on growth, apoptosis, invasion, and EMT were determined by cell counting kit-8 (CCK-8), western blot, flow cytometry, and transwell assays in retinoblastoma cells. Y79 cells were injected into the vitreous cavity of BALB/c‑nude mice to construct a retinoblastoma mouse model. Tumor growth and mouse weight were monitored for sequential 5 weeks. The effect of GPS in vivo was assessed by immunohistochemistry (IHC), terminal deoxynucleotidyl transferase deoxyuridine triphosphate (dUTP) nick end labeling (TUNEL), and western blot assays. GPS decreased the cell viability of both Y79 and Weri-Rb1 cells with the IC50 of 18.85 μM and 27.57 μM, respectively. Besides, GPS reduced the relative expression of proteins involved in proliferation and EMT, and the number of invading cells, while increased the apoptosis rate and the relative expressions of apoptosis proteins in retinoblastoma cells. Mechanically, GPS decreased the relative protein level of PI3K/AKT pathway, which was then recovered after 740 Y-P was applied. Correspondingly, 740 Y-P reversed the inhibitory effect of GPS on growth, invasion, and EMT, and the increased effect of GPS on apoptosis. Additionally, GPS decreased tumor volume and weight as well as the relative level of Ki-67, VEGF, p-PI3K/PI3K, and p-AKT/AKT, while increased the apoptosis rate in vivo. GPS inhibited retinoblastoma cell proliferation and invasion via deactivating the PI3K/AKT pathway in both cell and animal models.

Quality of life among people with eye cancer: a systematic review from 2012 to 2022

BACKGROUND

Eye cancer is a serious eye disease that threatens patients' lives. In the past decade, there have been more and more studies on eye cancer. From the recently published eye cancer literature review, it can be seen that the two most popular research hotspots are retinoblastoma (RB) and uveal melanoma (UM) [1, 2]. Although several studies have assessed QOL in different types of eye cancer patients, a study that synthesizes the factors influencing QOL in eye cancer patients is yet to be undertaken. This study aimed to review and evaluate the literature related to the QOL of RB and UM survivors, and provide a synthesis of the current evidence on the impact of the two types of eye cancer on the overall QOL of patients.

METHODS

Eight databases (APA Psych Articles, CINAHL Complete, Health Source: Nursing/Academic Edition, MEDLINE Complete, Scopus, Cochrane Library, PubMed, and Registers (Clinicaltrials.gov.)) were searched between January 2012 and December 2022 for English, peer-reviewed quantitative original studies within this review. All publications were screened using the Preferred Reporting Items for Systematic Review and Meta-Analyses reporting guidelines. The methodological quality of the reviews was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. The findings were summarised and tabulated accordingly.

RESULTS

Seventeen articles were analysed. Among them, 14 articles on patients with UM, and three articles on patients with RB using 18 different types of measurement tools were included. Eight researchers claimed that the overall QOL of patients with eye cancer was better than or similar to that of the general healthy population. However, nine studies indicated that these patients had poorer QOL than others. Many factors affect QOL, including treatment, sex, and age.

CONCLUSION

This systematic review identified the QOL levels and several factors that influence the QOL of ocular cancer patients worldwide, due to the variability in quality of the studies, it also showed the need for further research to assess factors affecting long-term QOL outcomes in RB and UM survivors. Simultaneously, it clarified the necessity and importance of developing standardized and complete assessment tools to compare QOL in different countries. Early interventions can be developed to improve the survivors' QOL by identifying potential deficits in specific areas.

Advancements in Retinoblastoma Treatment: Unraveling the Potential of Intravitreal Chemotherapy

Retinoblastoma necessitates urgent attention due to its potential fatality if untreated. Multiple treatment options are available and should be employed according to size, location, and the extent of dissemination. This review emphasizes the need for increased awareness, advanced diagnostic tools, and innovative treatment approaches, especially intravitreal chemotherapy (IVitC) to address the diverse manifestations and aggressive nature of retinoblastoma. Timely diagnosis and commitment to treatment are pivotal, as delays and reluctance to undergo enucleation contribute to unfavorable outcomes. The evolving treatment landscape, spanning from traditional interventions to modern targeted therapies such as intravitreal melphalan, holds promise for improved outcomes. While the intravitreal approach presents challenges, ongoing research aims to establish its definitive role in retinoblastoma treatment. In the treatment of retinoblastoma, IVitC raises considerations about side effects. The risk of tumor spread beyond the eye is rare, emphasising the potential of IVitC in carefully selected cases. Intravitreal injections exhibit fewer local adverse effects compared to intra-arterial chemotherapy, with careful measures reducing significant ocular complications. The evaluation of ocular toxicity, particularly with melphalan, underscores the importance of a nuanced approach to achieve the right balance between therapeutic efficacy and ocular safety. This comprehensive analysis of studies on IVitC and its ocular and systemic complications provides valuable insights for enhanced patient care. The review concludes with a focus on balancing safety and efficacy in local chemotherapeutic drugs, highlighting the need for thoughtful measures and continued research to optimise treatment modalities globally.

Lung cavitation to pneumothorax: A case report of the multilayered respiratory challenges in oncology patients

INTRODUCTION

The management of patients with complex oncological histories poses unique challenges, particularly when they are on targeted chemotherapy agents known for specific side effects. This case report illuminates the multifaceted complexities encountered in such scenarios, with a focus on the rare complications associated with targeted therapies.

CASE PRESENTATION

We present a 50-year-old male with an extensive oncological background, including childhood retinoblastoma and radiation-induced leiomyosarcoma. Recently diagnosed with skull base osteosarcoma, he was undergoing treatment with Regorafenib. Admitted with sepsis due to Pseudomonas aeruginosa-induced community-acquired pneumonia, his clinical course was complicated by lung cavitation leading to a spontaneous pneumothorax. This report highlights the absence of empyema, a crucial differential in the diagnosis.

DISCUSSION

This case unravels the intricate interplay between targeted chemotherapy, concurrent medications like prednisone, and their potential to cause severe complications such as pneumonia and pneumothorax. It delves into the mechanisms by which Regorafenib can lead to lung cavitation and abscess formation, a rare but significant risk. The importance of a multidisciplinary approach for prompt diagnosis and treatment, including surgical intervention, is highlighted. The pathology of the surgically resected lobe revealed metastatic high-grade leiomyosarcoma, adding another layer of complexity to the case.

CONCLUSION

This case serves as a cautionary tale highlighting the need for vigilant monitoring of patients on targeted chemotherapy agents, especially those with complex medical histories. It highlights the importance of considering potential drug-related complications and the rationale behind therapeutic choices, including antibiotic selection and surgical decision-making, in the management of acute medical conditions in these patients.

Conservative treatment using laser diode and systemic chemotherapy for early-stage bilateral retinoblastoma: A 14-year prospective cohort study

BACKGROUND

Solid evidence of the safety and effectiveness of retinoblastoma (RB) conservative treatment using thermotherapy and systemic chemotherapy with long-term follow-up is scarce, especially in low-resource countries.

AIMS

This study examined the outcomes of this treatment and associated predictors in Vietnam to strengthen the current RB treatment protocol focusing on preserving eye and vision in low-resource settings.

METHODS AND RESULTS

A prospective cohort study was conducted at Ho Chi Minh City Eye Hospital in Vietnam from 2005 to 2019. All eligible patients with bilateral RB (one eye already removed and another eye classified as group A or B) and without previous treatment were recruited. All patients received thermotherapy and six cycles of systemic three-agent chemotherapy repeated every 4 weeks. A standardized questionnaire was used to collect information on study participants' age, symptoms, tumor characteristics, treatment, and outcomes. Among 50 eyes of all 50 patients with a median age of 9 (4-20) months, 34 eyes were in group B (68%). The median follow-up time was 60 (60-84) months. All 139 preserved tumors regressed mostly to type 4 (70.4%) and type 3 (23.7%) scars. Kaplan-Meier analysis found the overall globe-salvage rate at 5 years of 91.9% (95% CI: 80.1%-97.7%). Most eyes (41/50, 82%, 95% CI: 69.2%-90.2%) had a final visual acuity ≥0.1. The visual acuity is higher when tumors regressed to a type 4 scar (p = .007, AOR = 8.098, 95% CI: 1.79-36.53) which also shows less enucleation than a type 3 scar (p = .002, AOR = 0.06, 95% CI: 0.01-0.37%). Gender effect on visual acuity after treatment was significant and may be due to discrimination. No major complications were recorded.

CONCLUSION

Conservative treatment of early-stage RB is safe and effective. Long-term, thorough follow-ups of patients post-treatment are needed. The regression patterns of scars could be a useful indicator of treatment failure.

Preoperative Detection of Local Tumor Extent in Patients with Advanced Retinoblastoma: Predictive Value of MRI and Clinical Findings

OBJECTIVE

Before planned enucleation, local tumor extension in advanced retinoblastoma is routinely assessed preoperatively using high-resolution magnetic resonance imaging (MRI). The aim of our study was to analyse the predictive value of MRI and clinical characteristics for predicting tumor extent, as confirmed by histopathology postoperatively.

PATIENTS AND METHODS

All consecutive patients were included who underwent primary enucleation for advanced retinoblastoma after high-resolution MRI examination in our hospital between January 2011 and December 2021. The primary study endpoint was the evaluation of the predictability of histopathological risk factors on preoperative MRI examination. The sensitivity and specificity of the MRI examination with respect to clinically relevant optic nerve infiltration and choroidal infiltration were determined.

RESULTS

The mean age of the 209 included patients was 1.6 years (range 1 month to 4.7 years). MRI indicated optic nerve infiltration in 46 (22%) patients, extensive choroidal infiltration in 78 (40.2%) patients, and scleral infiltration in one patient (2.6%). Histopathological examination demonstrated postlaminar optic infiltration in 25 (12%) patients and extensive choroidal infiltration in 17 (8.1%) cases. Scleral infiltration was evident in 8 (3.8%) patients. In the final multivariate analysis, MRI findings of tumor infiltration and a preoperative intraocular pressure ≥ 20 mmHg were independently associated with histopathological evidence of clinically relevant optic nerve (p = 0.033/p = 0.011) and choroidal infiltration (p = 0.005/p = 0.029). The diagnostic accuracy of the prediction models based on the multivariate analysis for the identification of the clinically relevant optic nerve (AUC = 0.755) and choroidal infiltration (AUC = 0.798) was greater than that of purely MRI-based prediction (respectively 0.659 and 0.742). The sensitivity and specificity of MRI examination for determining histopathological risk factors in our cohort were 64% and 65% for clinically relevant optic infiltration and 87% and 64% for clinically relevant choroidal infiltration.

CONCLUSION

The local tumor extent of retinoblastoma with infiltration of the optic nerve and choroid can be well estimated based on radiological and clinical characteristics before treatment initiation. The combination of clinical and radiological risk factors supports the possibility of early treatment stratification in retinoblastoma patients.