The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background

Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival.

Methods

We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models.

Findings

The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope).

Interpretation

This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.

Funding

Queen Elizabeth Diamond Jubilee Trust.

Global Retinoblastoma Presentation and Analysis by National Income Level

Importance

Early diagnosis of retinoblastoma, the most common intraocular cancer, can save both a child's life and vision. However, anecdotal evidence suggests that many children across the world are diagnosed late. To our knowledge, the clinical presentation of retinoblastoma has never been assessed on a global scale.

Objectives

To report the retinoblastoma stage at diagnosis in patients across the world during a single year, to investigate associations between clinical variables and national income level, and to investigate risk factors for advanced disease at diagnosis.

Design, Setting, and Participants

A total of 278 retinoblastoma treatment centers were recruited from June 2017 through December 2018 to participate in a cross-sectional analysis of treatment-naive patients with retinoblastoma who were diagnosed in 2017.

Main Outcomes and Measures

Age at presentation, proportion of familial history of retinoblastoma, and tumor stage and metastasis.

Results

The cohort included 4351 new patients from 153 countries; the median age at diagnosis was 30.5 (interquartile range, 18.3-45.9) months, and 1976 patients (45.4%) were female. Most patients (n = 3685 [84.7%]) were from low- and middle-income countries (LMICs). Globally, the most common indication for referral was leukocoria (n = 2638 [62.8%]), followed by strabismus (n = 429 [10.2%]) and proptosis (n = 309 [7.4%]). Patients from high-income countries (HICs) were diagnosed at a median age of 14.1 months, with 656 of 666 (98.5%) patients having intraocular retinoblastoma and 2 (0.3%) having metastasis. Patients from low-income countries were diagnosed at a median age of 30.5 months, with 256 of 521 (49.1%) having extraocular retinoblastoma and 94 of 498 (18.9%) having metastasis. Lower national income level was associated with older presentation age, higher proportion of locally advanced disease and distant metastasis, and smaller proportion of familial history of retinoblastoma. Advanced disease at diagnosis was more common in LMICs even after adjusting for age (odds ratio for low-income countries vs upper-middle-income countries and HICs, 17.92 [95% CI, 12.94-24.80], and for lower-middle-income countries vs upper-middle-income countries and HICs, 5.74 [95% CI, 4.30-7.68]).

Conclusions and Relevance

This study is estimated to have included more than half of all new retinoblastoma cases worldwide in 2017. Children from LMICs, where the main global retinoblastoma burden lies, presented at an older age with more advanced disease and demonstrated a smaller proportion of familial history of retinoblastoma, likely because many do not reach a childbearing age. Given that retinoblastoma is curable, these data are concerning and mandate intervention at national and international levels. Further studies are needed to investigate factors, other than age at presentation, that may be associated with advanced disease in LMICs.

[Effectiveness of primary care physicians and dermatologists in the diagnosis of skin cancer: a comparative study in the same geographic area]

BACKGROUND

skin cancer is the most common malignant tumor in white individuals. Early diagnosis and treatment are key factors in reducing morbidity. We performed a prospective observational study throughout 2008 to assess the ability of primary care physicians to diagnose nonmelanoma skin cancer.

METHODS

the study was undertaken in a single geographic area corresponding to the region served by a primary health care center. Patients who were referred to a dermatologist were included if the primary care physician indicated skin cancer in the differential diagnosis on the referral form. Patients were also included if the dermatologist suspected skin cancer even if the referral from primary care had not indicated it.

RESULTS

primary care physicians had a sensitivity of 0.45 and a specificity of 0.16 for the diagnosis of skin cancer, whereas dermatologists had a sensitivity of 0.97 and a specificity of 0.75. The α statistic as a measure of agreement was -0.56.

CONCLUSIONS

The ability of primary care physicians to diagnose skin cancer was appreciably lower than that of dermatologists. This may result in substantial delays in the provision of appropriate care for patients with skin cancer considering the role played by primary care physicians in screening for the disease in the Spanish national health system.

[Changes in incidence of malignant melanoma in the last 19 years in a tertiary hospital on the Mediterranean coast]

INTRODUCTION

The incidence of melanoma has increased more than that of any other type of malignant tumor. Our aim was to analyze the changes in incidence of cutaneous melanoma in recent years in a Mediterranean population.

MATERIAL AND METHODS

Patients with melanoma diagnosed between 1988 and 2006 were included in the study. Data from the first half of this period were compared with data from the second half.

RESULTS

The number of in situ melanomas increased from 36/302 cases (11.92 %) in the first half of the period to 224/724 (30.94 %) in the second half. Melanomas measuring more than 4 mm increased from 29/302 cases (9.60 %) to 62/724 (8.56 %). The mean maximum thickness for the whole study period was 1.91 mm and was similar for both halves.

CONCLUSIONS

The increase in incidence of melanoma in our population was due mainly to an increase in incipient cases. The proportion of melanomas larger than 4 mm remained constant, although, in absolute terms, twice as many such melanomas were detected per year. We believe that campaigns for prevention and early detection must continue, and should focus in particular on the older population.

[Minor cutaneous ambulatory surgery and cryotherapy. Comparative study between a dermatologist and family physicians]

INTRODUCTION

Lack of diagnostic skill in cutaneous surgery may lead to erroneous and potentially detrimental therapies. This study compares the diagnosis and treatment in cutaneous surgery, including cryotherapy, between a dermatologist and family physicians.

METHODS

It is an observational, prospective study on a random sample of patients that consulted the dermatologist for candidate lesions. Each lesion was independently evaluated by a dermatologist and a family physician, both of whom assigned the clinical diagnosis and therapeutic advice. Concordance for diagnosis, recommended treatment and indication for cryotherapy was calculated by Cohen's kappa coefficient.

RESULTS

Six hundred forty-six lesions were evaluated. Global kappa indexes were 0.69 (95 % CI, 0.65-0.73) for diagnostic concordance, 0.62 (95 % CI, 0.56-0.67) for recommended treatment and 0.73 (95 % CI, 0.67-0.78) for indication of cryotherapy. Diagnostic concordance was significantly better for melanocytic nevus, achrocordon and for lesions with multiple and monomorphous presentation, and worse for isolated pigmented lesions. For recommended treatment concordance was better for multiple and monomorphous lesions and worse for skin cancer and seborrheic keratosis. For indication of cryotherapy concordance was worse for skin cancer, melanocytic nevus, acrochordon and seborrheic keratosis. Family physicians made an erroneous indication for cryotherapy in 5.88 % of cases, including 3 non melanoma skin cancers.

CONCLUSIONS

Concordance between dermatologists and family physicians for minor cutaneous surgery is generally good. Family physicians should be more careful in evaluating solitary pigmented lesions and patients at risk for skin cancer.

The risk and risk factors of a second non-melanoma skin cancer: a study in a Mediterranean population

BACKGROUND

Non-melanoma skin cancer (NMSC) patients often develop second primary skin tumours. Studies assessing the risk and risk factors on the appearance of a second NMSC are scarce, especially in European countries.

OBJECTIVES

To assess the 5-year risk of a second NMSC in a Mediterranean population, and to find patient characteristics predicting second tumours.

METHODS

NMSC patients at our institution were studied retrospectively. In situ tumours, recurrences, follow-up shorter than 2 months and mucosal lesions were excluded. Data analysed included age, gender, anatomical site, histological subtype, number of tumours and months of follow-up. Disease-free interval was defined as time from histological documentation of the first NMSC to the date of the last follow-up or to the date of histological documentation of the second NMSC. Survival analysis was conducted with the life-table analysis. Cox's proportional hazards regression model was used to assess risk factors.

RESULTS

The study group comprised 535 cases. Of these, 120 patients presented a second NMSC (22.4%). Hazard rates remained high in all yearly intervals. Multivariate analysis showed older age, multiple tumours and male sex as significant prognostic factors. When the second NMSC was diagnosed in the first year of follow-up, a trend to a high risk of further NMSCs was observed.

CONCLUSIONS

The risk of a second NMSC is similar to other studies, although in the lower range. Prognostic factors are also similar to other studies. Yearly hazard rates not falling suggests that long-term follow-up is needed. Prospective studies including whole-body examination could define the exact risk of a second NMSC.

Cutaneous involvement in sarcoidosis. Relationship to systemic disease

Sarcoidosis is an antigen-mediated disease defined by granuloma formation in different organs. It involves mainly the mediastinal and peripheral lymph nodes, lungs, eyes, skin, liver, and spleen. Cutaneous lesions of sarcoidosis may be specific, showing histologically noncaseating granulomas, or nonspecific, most typically erythema nodosum. Frequently, both types of skin lesions are the means of presentation of the disease and may contribute to the diagnosis. A workup for systemic sarcoidosis should be undertaken in every patient with sarcoid cutaneous granulomas. Some types of cutaneous lesions have prognostic significance. Lupus pernio and plaques are associated with more severe systemic involvement and more chronic course, while erythema nodosum is the hallmark of acute and benign disease.

Angiogenesis and malignant melanoma. Angiogenesis is related to the development of vertical (tumorigenic) growth phase

To study angiogenesis in early steps of melanoma progression, 113 cutaneous melanomas 1 mm or less in thickness were stained with Ulex europaeus lectin. Vascular density was determined in the areas of greatest vascularization. To avoid the effect of anatomic location, the quotient between vascular density at the tumor base and in normal skin (vascular ratio) was obtained in each case. Of these melanomas, 46 were immunohistochemically stained for the presence of vascular endothelial growth factor (VEGF). Positivity was scored from 1-4 by comparing staining of melanoma cells with keratinocytes. Vascular ratio values in vertical growth phase melanomas were higher than those in radial growth phase when counting per 200 or 400 magnification (2.29 +/- 1.3 and 2.48 +/- 1.5 for vertical growth phase and 1.34 +/- 0.62 and 1.41 +/- 0.83 for radial growth phase melanomas, respectively). This difference was statistically significant (p < 0.0001 and p < 0.001 at x200 and x400, respectively). Also, VEGF staining was stronger in vertical growth phase melanomas when compared with radial growth phase melanomas (Chi square, p < 0.025). In conclusion, our findings suggest that angiogenesis and VEGF expression are associated with the development of vertical growth phase.

Salivary gland lymphoplasmacytoid lymphoma with nodular cutaneous amyloid deposition and lambda chain paraproteinaemia

We report the case of an 83-year-old woman who developed a lymphoplasmacytoid lymphoma of the salivary glands with extension to the skin of the cheeks and laterocervical area. The most remarkable feature was the massive amyloid deposition that gave the cutaneous lesions a distinctive clinical appearance, similar to that observed in cases of nodular cutaneous amyloidosis. An IgM-lambda paraprotein was also detected in the serum.