Array ( [0] => {{about|the disease|the protein|Retinoblastoma protein}} [1] => {{Infobox medical condition (new) [2] => | name = Retinoblastoma [3] => | synonyms = [4] => | image = Retinoblastoma_in_enucleated_eyeball.jpg [5] => | caption = A pathology specimen of a retinoblastoma tumor from an enucleated eye of a 3-year-old female [6] => | pronounce = [7] => | field = [[Neuro-oncology]] [8] => | [9] => | symptoms = [[Leukocoria]] seen in patient's pupil in photos
Poor vision
One or both eyes turning inward or outward
Eye pain{{Cite web|title=Retinoblastoma|url=https://www.stjude.org/disease/retinoblastoma.html|access-date=March 9, 2022|publisher=[[St. Jude Children's Research Hospital]]}} [10] => | complications = [11] => | onset = Under 3 years old [12] => | duration = [13] => | types = [14] => | causes = [15] => | risks = [16] => | diagnosis = [17] => | differential = [18] => | prevention = [19] => | treatment = Surgery (including eye removal in advanced cases)
[[Chemotherapy]] (after surgery in cases of metastasis)
Focal therapy [20] => | medication = [21] => | prognosis = [22] => | frequency = ~250–300 children diagnosed annually (United States) [23] => | deaths = [24] => }} [25] => '''Retinoblastoma''' (Rb) is a rare form of [[cancer]] that rapidly develops from the immature cells of a [[retina]], the light-detecting [[tissue (biology)|tissue]] of the eye. It is the most common primary malignant intraocular cancer in children, and it is almost exclusively found in young children.{{cite book |title=Cancer Medicine |last=American Cancer Society |year=2003 |publisher=BC Decker Inc |location=Hamilton, Ontario |isbn=978-1-55009-213-4 |chapter=Chapter 85. Neoplasms of the Eye |chapter-url=https://www.ncbi.nlm.nih.gov/books/bv.fcgi?highlight=Retinoblastoma&rid=cmed6.section.20082#20085 |url-access=registration |url=https://archive.org/details/cancermedicine60002unse }} [26] => [27] => Though most children in high income countries survive this cancer,{{cite journal |last1= Abramson |first1= David H. |last2= Chantada |first2= Guillermo L. |last3= Cobrinik |first3= David |last4= Corson |first4= Timothy W. |last5= Dimaras |first5= Helen |last6= Gallie |first6= Brenda L. |last7= Munier |first7= Francis L. |last8= Njuguna |first8= Festus |last9= Shields |first9= Carol L. |last10= White |first10= Abby |last11= Zhao |first11= Junyang |date= 2015 |title= Retinoblastoma |journal= [[Nature Reviews Disease Primers]] |volume= 1 |page= 15021 |doi= 10.1038/nrdp.2015.21 |pmid= 27189421 |pmc= 5744255 }} they may lose their vision in the affected eye(s){{cite journal |last1= Naeem |first1= Zishan |last2= Reddy |first2= M. Ashwin |last3= Roelofs |first3= Kelsey A. |last4= Sagoo |first4= Mandeep S. |last5= Warda |first5= Omar |date= 2022 |title= Retinoblastoma and vision |journal= [[Eye (journal)|Eye]] |volume= 37 |issue= 5 |pages= 797–808 |doi= 10.1038/s41433-021-01845-y |pmid= 34987197 |pmc= 10050411 |s2cid= 245672434 }} or need to have the [[Enucleation of the eye|eye removed]]. [28] => [29] => Almost half of children with retinoblastoma have a hereditary [[genetic defect]] associated with retinoblastoma. In other cases, it is caused by a [[congenital]] mutation in the [[chromosome 13]] gene 13q14 ([[retinoblastoma protein]]).{{cite book| vauthors = Ryan SJ, Schachat AP, Wilkinson CP, Hinton DR, Sadda SR, Wiedemann P |title=Retina|publisher=Elsevier Health Sciences|isbn=978-1455737802|page=2105|url=https://books.google.com/books?id=PdAsuzFRv5oC&pg=PA2105|language=en|date=2012-11-01}} [30] => [31] => ==Signs and symptoms== [32] => [[File:Rb whiteeye.PNG|thumb|Leukocoria in a child with retinoblastoma]] [33] => [[File:squint.jpg|thumb|Crossed eyes in a child with retinoblastoma]] [34] => Retinoblastoma is the most intrusive intraocular cancer among children. The chance of survival and preservation of the eye depends fully on the severity. Retinoblastoma is extremely rare as there are only about 200 to 300 cases every year in the United States. Globally, only 1 in about 15,000 children have this malignancy, though rates continue to increase.{{Cite web|title=Retinoblastoma - Symptoms and causes|url=https://www.mayoclinic.org/diseases-conditions/retinoblastoma/symptoms-causes/syc-20351008|access-date=2021-03-17|website=Mayo Clinic|language=en}} [35] => [36] => Intraocular malignancies are relatively more frequently treated than extraocular malignancies, likely due to a relatively earlier detection and subsequent treatment. Pediatricians may screen infants with annual vision tests, in which anomalies can be detected. During a red reflex test, light from an ophthalmoscope goes through transparent parts of the eye and reflects off the ocular fundus. If retinoblastoma is present, it may partially or fully impede light transversing this path. This may result in an [[Leukocoria|abnormal red reflex or leucocoria]], which can be a common indicator of retinoblastoma (when light is reflected by the tumor, the regular view of the red retina is blocked). The retinoblastoma may be visible as a whitish, translucent mass. If the tumor has not spread and is contained within the eye, chances of successful treatment are favorable. If initial signs are ignored or diagnosis is significantly delayed, outcomes and prognosis worsen. The effects of retinoblastoma may spread outside the eye, sometimes resulting in [[Exophthalmos|proptosis]]. Retinoblastoma that has spread may be significantly more difficult to treat. {{cite journal | vauthors = Dimaras H, Kimani K, Dimba EA, Gronsdahl P, White A, Chan HS, Gallie BL | title = Retinoblastoma | journal = Lancet | volume = 379 | issue = 9824 | pages = 1436–1446 | date = April 2012 | pmid = 22414599 | doi = 10.1016/s0140-6736(11)61137-9 | s2cid = 235331617 | doi-access = free }} [37] => [38] => The most common and obvious [[medical sign|sign]] of retinoblastoma is an abnormal appearance of the retina as viewed through the pupil, the medical term for which is [[leukocoria]], also known as amaurotic cat's eye reflex. Other signs and symptoms include deterioration of vision, a red and irritated eye with [[glaucoma]], and faltering growth or delayed development. Some children with retinoblastoma can develop a squint,{{cite journal | vauthors = Elkington AR, Khaw PT | title = ABC of eyes. Squint | journal = BMJ | volume = 297 | issue = 6648 | pages = 608–611 | date = September 1988 | pmid = 3139234 | pmc = 1834556 | doi = 10.1136/bmj.297.6648.608 }} commonly referred to as "cross-eyed" or "wall-eyed" ([[strabismus]]). Retinoblastoma presents with advanced disease in developing countries and eye enlargement is a common finding.{{Cite web |title=Retinoblastoma {{!}} National Eye Institute |url=https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/retinoblastoma |url-status=live |archive-url=https://web.archive.org/web/20220826025537/https://www.nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/retinoblastoma |archive-date=2022-08-26 |access-date=2022-08-26 |website=www.nei.nih.gov}} [39] => [40] => Depending on the position of the tumors, they may be visible during a simple eye examination using an [[ophthalmoscope]] to look through the [[pupil]]. A positive diagnosis is usually made only with an examination under anesthetic ([[List of medical abbreviations: E|EUA]]). A white eye reflection is not always a positive indication of retinoblastoma and can be caused by light being reflected badly{{cite web |url= https://chect.org.uk/about-retinoblastoma-2/whiteeye/ |title= Seen a white glow in a photograph? |website= chect.org.uk |date= 18 January 2017 |publisher= The Childhood Eye Cancer Trust |accessdate= 2022-12-31}} or by other conditions such as [[Coats' disease]].{{cite journal |last1= Balmer |first1= Aubin |last2= Munier |first2= Francis |date= 2007 |title= Differential diagnosis of leukocoria and strabismus, first presenting signs of retinoblastoma |journal= [[Clinical Ophthalmology (journal)|Clinical Ophthalmology]] |volume= 1 |issue= 4 |pages= 431–439 |pmid= 19668520 |pmc= 2704541 }} [41] => [42] => The presence of the photographic fault [[red-eye effect|red eye]] in only one eye and not in the other may be a sign of retinoblastoma. A clearer sign is "white eye" or "cat's eye" (leukocoria).[http://www.daisyfund.org/rb/leuko/index.html Introduction to White Eye] {{webarchive|url=https://web.archive.org/web/20110426225730/http://www.daisyfund.org/rb/leuko/index.html |date=2011-04-26 }}, Daisy's Eye Cancer Fund. [43] => [44] => == Cause == [45] => Mutation of genes, found in chromosomes, can affect the way in which cells grow and develop within the body.{{cite journal | vauthors = Du W, Pogoriler J | title = Retinoblastoma family genes | journal = Oncogene | volume = 25 | issue = 38 | pages = 5190–5200 | date = August 2006 | pmid = 16936737 | pmc = 1899835 | doi = 10.1038/sj.onc.1209651 }} Alterations in [[RB1]] or [[MYCN]] can give rise to retinoblastoma. [46] => [47] => === RB1 === [48] => In children with the heritable genetic form of retinoblastoma, a mutation occurs in the ''[[RB1]]'' gene on [[Chromosome 13 (human)|chromosome 13]].'' RB1'' was the first [[tumor suppressor gene]] cloned. Although'' RB1'' interacts with over 100 cell proteins, its negative regulator effect on the cell cycle principally arises from binding and inactivation of the [[transcription factor]] ''[[E2F]]'', thus repressing the transcription of genes which are required for the [[S phase]]. [49] => [50] => The defective ''RB1 ''gene can be inherited from either parent; in some children, however, the mutation occurs in the early stages of fetal development. The expression of the'' RB1 ''[[allele]] is [[Autosome|autosomal]] dominant with 90% [[penetrance]].{{Citation |last1=Lohmann |first1=Dietmar R. |title=Retinoblastoma |date=1993 |url=http://www.ncbi.nlm.nih.gov/books/NBK1452/ |work=GeneReviews® |editor-last=Adam |editor-first=Margaret P. |place=Seattle (WA) |publisher=University of Washington, Seattle |pmid=20301625 |access-date=2022-06-27 |last2=Gallie |first2=Brenda L. |editor2-last=Mirzaa |editor2-first=Ghayda M. |editor3-last=Pagon |editor3-first=Roberta A. |editor4-last=Wallace |editor4-first=Stephanie E.}} [51] => [52] => Inherited forms of retinoblastomas are more likely to be bilateral. In addition, inherited uni- or bilateral retinoblastomas may be associated with [[pinealoblastoma|pineoblastoma]] and other malignant midline supratentorial [[primitive neuroectodermal tumor]]s (PNETs) with a dismal outcome; retinoblastoma concurrent with a PNET is known as [[trilateral retinoblastoma]].{{cite journal | vauthors = Kivelä T | title = Trilateral retinoblastoma: a meta-analysis of hereditary retinoblastoma associated with primary ectopic intracranial retinoblastoma | journal = Journal of Clinical Oncology | volume = 17 | issue = 6 | pages = 1829–1837 | date = June 1999 | pmid = 10561222 | doi = 10.1200/JCO.1999.17.6.1829 }} A 2014 meta-analysis showed that 5-year survival of trilateral retinoblastoma increased from 6% before 1995 to 57% by 2014, attributed to early detection and improved chemotherapy.{{cite journal | vauthors = de Jong MC, Kors WA, de Graaf P, Castelijns JA, Kivelä T, Moll AC | title = Trilateral retinoblastoma: a systematic review and meta-analysis | journal = The Lancet. Oncology | volume = 15 | issue = 10 | pages = 1157–1167 | date = September 2014 | pmid = 25126964 | doi = 10.1016/s1470-2045(14)70336-5 }} [53] => [54] => The development of retinoblastoma can be explained by the [[Knudson hypothesis|two-hit model]]. According to the two-hit model, both alleles need to be affected, so two events are necessary for the retinal cell or cells to develop into tumors. The first mutational event can be inherited ([[germline mutation|germline]] or constitutional), which will then be present in all cells in the body. The second “hit” results in the loss of the remaining normal allele (gene) and occurs within a particular retinal cell.Harbour J.W., Dean D.C. Rb function in cell-cycle regulation and apoptosis" ''Nature Cell Biology.'' 2000;94:E65–E67. In the sporadic, nonheritable form of retinoblastoma, both mutational events occur within a single retinal cell after fertilization (somatic events); sporadic retinoblastoma tends to be unilateral. [55] => [56] => Several methods have been developed to detect the ''RB1'' gene mutations.{{cite journal | vauthors = Parsam VL, Kannabiran C, Honavar S, Vemuganti GK, Ali MJ | title = A comprehensive, sensitive and economical approach for the detection of mutations in the RB1 gene in retinoblastoma | journal = Journal of Genetics | volume = 88 | issue = 4 | pages = 517–527 | date = December 2009 | pmid = 20090211 | doi = 10.1007/s12041-009-0069-z | s2cid = 10723496 }}{{cite book |title=GeneReviews |vauthors=Lohmann DR, Gallie BL |year=2010 |publisher=University of Washington|location=Seattle, WA |chapter=Retinoblastoma |pmid=20301625}} Attempts to correlate gene mutations to the stage at presentation have not shown convincing evidence of a correlation.{{cite journal | vauthors = Ali MJ, Parsam VL, Honavar SG, Kannabiran C, Vemuganti GK, Reddy VA | title = RB1 gene mutations in retinoblastoma and its clinical correlation | journal = Saudi Journal of Ophthalmology | volume = 24 | issue = 4 | pages = 119–123 | date = October 2010 | pmid = 23960888 | pmc = 3729507 | doi = 10.1016/j.sjopt.2010.05.003 }} [57] => [58] => === MYCN === [59] => [60] => Not all retinoblastoma cases are with RB1 inactivation. There are cases reported with only one RB1 mutation or even two functional RB1 alleles, which indicates other oncogenic lesions of retinoblastoma.{{cite journal | vauthors = Rushlow DE, Mol BM, Kennett JY, Yee S, Pajovic S, Thériault BL, Prigoda-Lee NL, Spencer C, Dimaras H, Corson TW, Pang R, Massey C, Godbout R, Jiang Z, Zacksenhaus E, Paton K, Moll AC, Houdayer C, Raizis A, Halliday W, Lam WL, Boutros PC, Lohmann D, Dorsman JC, Gallie BL | display-authors = 6 | title = Characterisation of retinoblastomas without RB1 mutations: genomic, gene expression, and clinical studies | journal = The Lancet. Oncology | volume = 14 | issue = 4 | pages = 327–334 | date = April 2013 | pmid = 23498719 | doi = 10.1016/S1470-2045(13)70045-7 | doi-access = }} Somatic amplification of the ''[[MYCN]]'' [[oncogene]] is responsible for some cases of nonhereditary, early-onset, aggressive, unilateral retinoblastoma. MYCN can act as a transcription factor and promotes proliferation by regulating the expression of cell cycle genes.{{cite journal | vauthors = Woo CW, Tan F, Cassano H, Lee J, Lee KC, Thiele CJ | title = Use of RNA interference to elucidate the effect of MYCN on cell cycle in neuroblastoma | journal = Pediatric Blood & Cancer | volume = 50 | issue = 2 | pages = 208–212 | date = February 2008 | pmid = 17420990 | doi = 10.1002/pbc.21195 | s2cid = 22765085 }}{{cite journal | vauthors = Stenfelt S, Blixt MK, All-Ericsson C, Hallböök F, Boije H | title = Heterogeneity in retinoblastoma: a tale of molecules and models | journal = Clinical and Translational Medicine | volume = 6 | issue = 1 | pages = 42 | date = November 2017 | pmid = 29124525 | pmc = 5680409 | doi = 10.1186/s40169-017-0173-2 | doi-access = free }} Although ''MYCN'' amplification accounted for only 1.4% of retinoblastoma cases, researchers identified it in 18% of infants diagnosed at less than 6 months of age. Median age at diagnosis for ''MYCN'' retinoblastoma was 4.5 months, compared with 24 months for those who had nonfamilial unilateral disease with two ''RB1 ''gene mutations.{{cite journal | vauthors=Lewis R | title=Some Aggressive Retinoblastomas Lack RB1 Mutations | journal=Medscape Online | date=March 19, 2013 | url=http://www.medscape.com/viewarticle/781040 | url-status=live | archive-url=https://web.archive.org/web/20170919082102/http://www.medscape.com/viewarticle/781040 | archive-date=September 19, 2017 }} [61] => [62] => ==Diagnosis== [63] => [[File:Rb_Retina_Scan.jpg|thumb|left| Rb tumors taken with a retinoscan before and during chemotherapy]] [64] => Screening for retinoblastoma should be part of a "well baby" screening for newborns during the first 3 months of life, to include:{{cite journal |last1= Bowman |first1= Richard |last2= Evans |first2= Jennifer R. |last3= Gilbert |first3= Clare |last4= Gordon |first4= Iris |last5= Gupta |first5= Sunchita |last6= Malik |first6= Aeesha NJ |last7= Mariotti |first7= Silvio |date= 2022 |title= Universal newborn eye screening: a systematic review of the literature and review of international guidelines |url= https://researchonline.lshtm.ac.uk/id/eprint/4667929/1/jogh-12-12003.pdf |journal= Journal of Global Health |volume= 12 |page= 12003 |doi= 10.7189/jogh.12.12003 |pmid= 36269293 |pmc= 9586142 |accessdate= 2022-12-31}} [65] => * The [[red reflex]]: checking for a normal reddish-orange reflection from the eye's retina with an ophthalmoscope or retinoscope from about 30 cm or 1 foot, usually done in a dimly lit or dark room [66] => * The corneal light reflex or [[Hirschberg test]]: checking for symmetrical reflection of beam of light in the same spot on each eye when a light is shined into each cornea, to help determine whether the eyes are crossed [67] => * [[Eye examination]]: checking for any structural abnormalities [68] => [69] => ===Classification=== [70] => The two forms of the disease are a [[heritable]] form and [[Non-heritable variations|nonheritable]] form (all cancers are considered genetic in that mutations of the genome are required for their development, but this does not imply that they are heritable, or transmitted to offspring). Approximately 40% of patients have a heritable form of retinoblastoma, carrying a mutation in the ''RB1'' gene.{{cite journal |last1= Abramson |first1= David H. |last2= Barnea |first2= Dana |last3= Bosscha |first3= Machted I. |last4= Chantada |first4= Guillermo |last5= de Graaf |first5= Pim |last6= Dommering |first6= Charlotte J. |last7= Dunkel |first7= Ira J. |last8= Fabius |first8= Armida W.M. |last9= Francis |first9= Jasmine H. |last10= Greer |first10= Mary-Louise G. |last11= Kleinerman |first11= Ruth A. |last12= Kors |first12= Wijnanda A. |last13= Laughlin |first13= Suzanne |last14= Moll |first14= Annette C. |last15= Morton |first15= Lindsay M. |last16= Novetsky Friedman |first16= Danielle |last17= Oeffinger |first17= Kevin C. |last18= Temming |first18= Petra |last19= Tonorezos |first19= Emily S. |last20= Tucker |first20= Margaret A. |last21= van Leeuwen |first21= Flora E. |last22= Walsh |first22= Michael F. |date= 2020 |title= Recommendations for long-term follow-up of adults with heritable retinoblastoma |journal= Ophthalmology |volume= 127 |issue= 11 |pages= 1549–1557 |doi= 10.1016/j.ophtha.2020.05.024 |pmid= 32422154 |pmc= 7606265 }} If no history of the disease exists within the family, the disease is labeled "sporadic", but this does not necessarily indicate that it is the nonheritable form. Bilateral retinoblastomas are commonly heritable, while unilateral retinoblastomas are commonly nonheritable.{{citation needed|date=July 2021}} [71] => [72] => In about two-thirds of cases,{{cite journal | vauthors = MacCarthy A, Birch JM, Draper GJ, Hungerford JL, Kingston JE, Kroll ME, Onadim Z, Stiller CA, Vincent TJ, Murphy MF | display-authors = 6 | title = Retinoblastoma in Great Britain 1963-2002 | journal = The British Journal of Ophthalmology | volume = 93 | issue = 1 | pages = 33–37 | date = January 2009 | pmid = 18838413 | doi = 10.1136/bjo.2008.139618 | s2cid = 27049728 }} only one eye is affected (unilateral retinoblastoma); in the other third, tumors develop in both eyes (bilateral retinoblastoma). The number and size of tumors on each eye may vary. In certain cases, the [[pineal gland]] or the [[suprasellar]] or [[parasellar]] region (or in very rare cases other midline intracranial locations) is also affected (trilateral retinoblastoma). The position, size, and quantity of tumors are considered when choosing the type of treatment for the disease.{{citation needed|date=July 2021}} [73] => [74] => ===Differential diagnosis=== [75] => [[File:MRI retinoblastoma.jpg|thumb|MRI pattern of retinoblastoma with optic nerve involvement (sagittal enhanced T1-weighted sequence)]] [76] => [77] => :1. [[Persistent fetal vasculature]] is a congenital developmental anomaly of the eye resulting from failure of the embryological, primary vitreous, and hyaloid vasculature to regress, whereby the eye is shorter, develops a cataract, and may present with whitening of the pupil. [78] => :2. [[Coats disease]] is a typically unilateral disease characterised by abnormal development of blood vessels behind the retina, leading to blood vessel abnormalities in the retina and retinal detachment to mimic retinoblastoma. [79] => :3. [[Toxocariasis]] is a parasitic disease of the eye associated with exposure to infected puppies, which causes a retinal lesion leading to retinal detachment. [80] => :4. [[Retinopathy of prematurity]] is associated with low-birth-weight infants who receive supplemental oxygen in the period immediately after birth, and it involves damage to the retinal tissue and may lead to retinal detachment. [81] => :5. [[Congenital cataract|Congenital Cataract]] [82] => :6. [[Norrie disease|Norrie Disease]] [83] => [84] => If the eye examination is abnormal, further testing may include imaging studies, such as [[computerized tomography]] (CT), [[magnetic resonance imaging]] (MRI), and [[ultrasound]].{{cite journal | vauthors = de Jong MC, de Graaf P, Noij DP, Göricke S, Maeder P, Galluzzi P, Brisse HJ, Moll AC, Castelijns JA | display-authors = 6 | title = Diagnostic performance of magnetic resonance imaging and computed tomography for advanced retinoblastoma: a systematic review and meta-analysis | journal = Ophthalmology | volume = 121 | issue = 5 | pages = 1109–1118 | date = May 2014 | pmid = 24589388 | doi = 10.1016/j.ophtha.2013.11.021 }} CT and MRI can help define the structure abnormalities and reveal any calcium depositions. Ultrasound can help define the height and thickness of the tumor. [[Bone marrow]] examination or [[lumbar puncture]] may also be done to determine any [[Metastasis|metastases]] to bones or the brain.{{citation needed|date=September 2021}} [85] => [86] => ===Morphology=== [87] => Gross and microscopic appearances of retinoblastoma are identical in both hereditary and sporadic types. Macroscopically, viable tumor cells are found near blood vessels, while zones of necrosis are found in relatively avascular areas. Microscopically, both undifferentiated and differentiated elements may be present. Undifferentiated elements appear as collections of small, round cells with hyperchromatic nuclei; differentiated elements include [[Flexner-Wintersteiner rosette]]s, [[Homer Wright rosette]]s,{{cite book| vauthors = Sehu WK, Lee W |title=Ophthalmic pathology : an illustrated guide for clinicians|year=2005|publisher=Blackwell Publishing|location=Malden|isbn=978-0-7279-1779-9|pages=262|url=https://books.google.com/books?id=kwYeEqWd4dUC&q=retinoblastoma+homer&pg=PA262}} and fleurettes from photoreceptor differentiation.{{cite book | vauthors = Kumar V, Abbas AK, Fausto N |title=Robbins pathologic basis of disease. |date=1999 |publisher=Saunders |location=Philadelphia |isbn=978-0-7216-0187-8 |edition=6th | page = 1442 }} [88] => {{clear}} [89] => [90] => Image:Wardrop retinoblastoma.jpg|Drawing of a large retinoblastoma [91] => Image:Trilateral retinoblastoma.jpg|Aspect of trilateral retinoblastoma on MRI [92] => Image:Retinoblastoma ultrasound.jpg|An ocular ultrasound of a large retinoblastoma tumor within the eye of a 3-year-old boy [93] => Image:Retinoblastooma.jpg|Funduscopic finding of a retinoblastoma [94] => Image:Fundus retinoblastoma.jpg|Ocular fundus aspect of retinoblastoma [95] => Image:Retinoblastoma .jpg|Large exophytic white tumor with foci of calcification producing total exudative retinal detachment [96] => Image:Retinoblastoma rosette.jpg|Flexner-Wintersteiner rosettes in retinoblastoma [97] => Image:Rtbl400.GIF|Retinoblastoma, 400 X magnification [98] => Image:RB1.JPG|Crystal structure of the retinoblastoma tumor suppressor protein bound to E2F peptide polymer [99] => [100] => [101] => === Genetic testing === [102] => Identifying the ''RB1'' gene mutation that led to a child's retinoblastoma can be important in the clinical care of the affected individual and in the care of (future) siblings and offspring. It may run in the family. [103] => # Bilaterally affected individuals and 13-15% of unilaterally affected individuals,{{cite journal | vauthors = Schüler A, Weber S, Neuhäuser M, Jurklies C, Lehnert T, Heimann H, Rudolph G, Jöckel KH, Bornfeld N, Lohmann DR | display-authors = 6 | title = Age at diagnosis of isolated unilateral retinoblastoma does not distinguish patients with and without a constitutional RB1 gene mutation but is influenced by a parent-of-origin effect | journal = European Journal of Cancer | volume = 41 | issue = 5 | pages = 735–740 | date = March 2005 | pmid = 15763650 | doi = 10.1016/j.ejca.2004.12.022 }}{{cite journal | vauthors = Rushlow D, Piovesan B, Zhang K, Prigoda-Lee NL, Marchong MN, Clark RD, Gallie BL | title = Detection of mosaic RB1 mutations in families with retinoblastoma | journal = Human Mutation | volume = 30 | issue = 5 | pages = 842–851 | date = May 2009 | pmid = 19280657 | doi = 10.1002/humu.20940 | s2cid = 31887184 }} are expected to show an ''RB1'' mutation in blood. By identifying the ''RB1'' mutation in the affected individual, (future) siblings, children, and other relatives can be tested for the mutation; if they do not carry the mutation, child relatives are not at risk of retinoblastoma, so need not undergo the trauma and expense of examinations under anaesthetic.{{cite journal | vauthors = Richter S, Vandezande K, Chen N, Zhang K, Sutherland J, Anderson J, Han L, Panton R, Branco P, Gallie B | display-authors = 6 | title = Sensitive and efficient detection of RB1 gene mutations enhances care for families with retinoblastoma | journal = American Journal of Human Genetics | volume = 72 | issue = 2 | pages = 253–269 | date = February 2003 | pmid = 12541220 | pmc = 379221 | doi = 10.1086/345651 }} For the 85% of unilaterally affected patients found not to carry either of their eye tumor'' RB1'' mutations in blood, neither molecular testing nor clinical surveillance of siblings is required. [104] => # If the ''RB1'' mutation of an affected individual is identified, amniotic cells in an at-risk pregnancy can be tested for the family mutation; any fetus that carries the mutation can be delivered early, allowing early treatment of any eye tumors, leading to better visual outcomes. [105] => # For cases of unilateral retinoblastoma where no eye tumor is available for testing, if no ''RB1'' mutation is detected in blood after high-sensitivity molecular testing (i.e. >93%'' RB1'' mutation detection sensitivity), the risk of a germline ''RB1'' mutation is reduced to less than 1%, a level at which only clinic examination (and not examinations under anaesthetic) is recommended for the affected individual and their future offspring (National Retinoblastoma Strategy, Canadian Guidelines for Care).{{cite journal | author = Canadian Ophthalmological Society | title = National Retinoblastoma Strategy Canadian Guidelines for Care | journal = Canadian Journal of Ophthalmology | volume = 44 | issue = suppl.2 | pages = S1-88 | date = December 2009 | pmid = 20237571 | doi = 10.3129/i09-194 | url = http://www.eyesite.ca/resources/CPGs/COS_RetinoblastomaCPGs_Dec09.pdf | url-status = dead | archive-url = https://web.archive.org/web/20110929000637/http://www.eyesite.ca/resources/CPGs/COS_RetinoblastomaCPGs_Dec09.pdf | archive-date = 2011-09-29 }} [106] => [107] => === Imaging === [108] => Traditional ultrasound B scan can detect calcifications in the tumour while high-frequency ultrasound B scan is able to provide higher resolution than the traditional ultrasound and determine the proximity of the tumour with front portion of the eye. MRI scan can detect high-risk features such as optic nerve invasion; choroidal invasion, scleral invasion, and intracranial invasion. CT scan is generally avoided because radiation can stimulate the formation of more eye tumours in those with RB1 genetic mutation.{{cite journal | vauthors = Dimaras H, Corson TW | title = Retinoblastoma, the visible CNS tumor: A review | journal = Journal of Neuroscience Research | volume = 97 | issue = 1 | pages = 29–44 | date = January 2019 | pmid = 29314142 | pmc = 6034991 | doi = 10.1002/jnr.24213 }} [109] => [110] => == Staging == [111] => In order to properly diagnose retinoblastoma, there must be guidelines to follow to properly classify the risk of the tumor. The ''Reese Ellsworth Classification System,'' by Dr. Algernon Reese and Dr. Robert Ellsworth, is universally used to determine the size, location, and multi-focality of the tumor.{{cite journal | vauthors = Chawla B, Jain A, Azad R | title = Conservative treatment modalities in retinoblastoma | journal = Indian Journal of Ophthalmology | volume = 61 | issue = 9 | pages = 479–485 | date = September 2013 | pmid = 24104705 | pmc = 3831762 | doi = 10.4103/0301-4738.119424 | doi-access = free }} The system was originally used to decide the best treatment result by using external beam radiotherapy, as well as, the likeliness of salvaging the globe of the eye. Due to [[chemotherapy]] not being part of the ''Reese Ellsworth Classification System,'' there needed to be an updated classification system to foresee the treatment outcomes of chemotherapy. The International Classification for Intraocular Retinoblastoma is now the current system being used, and it was created by Murphree and associates. According to Reese and Ellsworth, there were different groups that had various features in order to classify the globe salvage as very favorable to the category of very unfavorable. In order to salvage the affected eye, the disc diameter had to be around 4DD and behind the equator to have higher favorability. If the tumor was around ten in disc diameter and involved roughly 50% of the retina, it was considered unfavorable to salvage the globe which could result in [[Enucleation of the eye|enucleation]]. According to Murphree, the different groups were classified from very low risk to very high risk which was determined by features of the given tumor. Very low risk means that the tumor has to be less than 3mm and there must be no seeding of the [[Vitreous body|vitreous]] or sub-retinal area. When a patient is very high risk, the tumor presents itself with multiple features and is going to have to be treated with conservative treatment modalities or enucleation.{{cite journal | vauthors = Fabian ID, Reddy A, Sagoo MS | title = Classification and staging of retinoblastoma | journal = Community Eye Health | volume = 31 | issue = 101 | pages = 11–13 | date = 2018 | pmid = 29915461 | pmc = 5998397 }} [112] => {| class="wikitable" [113] => |'''Group''' [114] => |'''Clinical Features''' [115] => |- [116] => |A [117] => Very low risk [118] => |All tumors are 3mm or smaller, confined to the retina, and located at least 3mm from the foveola and 1.5mm from the optic nerve. No vitreous or subretinal seeding [119] => |- [120] => |B [121] => Low risk [122] => |Retinal tumors may be any size or location not in Group A, No vitreous or subretinal seeding allowed. A small cuff of subretinal fluid extending no more than 5mm from the base of the tumor is allowed [123] => |- [124] => |C [125] => Moderate risk [126] => |Eyes with only focal vitreous or subretinal seeding and discrete retinal tumors of any size and location. Vitreous or subretinal seeding may extend no more than 3mm from the tumor. Up to one quadrant of subretinal fluid may be present [127] => |- [128] => |D [129] => High risk [130] => |Eyes with diffuse vitreous or subretinal seeding and/or massive, nondiscrete endophytic or exophytic disease. More than one quadrant of retinal detachment [131] => |- [132] => |E [133] => Very high risk eyes [134] => |Eyes with one or more of the following: [135] => Irreversible neovascular glaucoma [136] => [137] => Massive intraocular hemorrhage [138] => [139] => Aseptic orbital cellulitis [140] => [141] => Phthisis or pre-phthisis [142] => [143] => Tumor anterior to anterior vitreous face [144] => [145] => Tumor touching the lens [146] => [147] => Diffuse infiltrating retinoblastoma [148] => |} [149] => International Classification for Intraocular Retinoblastoma [150] => [151] => ==Treatment== [152] => [[File:External beam radiotherapy retinoblastoma nci-vol-1924-300.jpg|thumb|Historical image showing Gordon Isaacs, the first patient treated with the linear accelerator ([[external beam radiation therapy]]) for retinoblastoma, in 1957. Gordon's right eye was removed January 11, 1957 because the cancer had spread. His left eye, however, had only a localized tumor that prompted [[Henry Kaplan (doctor)|Henry Kaplan]] to try to treat it with the electron beam.]] [153] => [154] => The priority of retinoblastoma treatment is to preserve the life of the child, then to preserve vision, and then to minimize complications or side effects of treatment. The exact course of treatment depends on the individual case and is decided by the ophthalmologist in discussion with the paediatric oncologist.{{cite journal | vauthors = Chintagumpala M, Chevez-Barrios P, Paysse EA, Plon SE, Hurwitz R | title = Retinoblastoma: review of current management | journal = The Oncologist | volume = 12 | issue = 10 | pages = 1237–1246 | date = October 2007 | pmid = 17962617 | doi = 10.1634/theoncologist.12-10-1237 | citeseerx = 10.1.1.585.5448 | s2cid = 15465073 }} Correct treatment also depends on the mutation type, whether it is a germline RB1 mutation, a sporadic RB1 mutation or MYCN amplification with functional RB1.{{cite journal | vauthors = Li WL, Buckley J, Sanchez-Lara PA, Maglinte DT, Viduetsky L, Tatarinova TV, Aparicio JG, Kim JW, Au M, Ostrow D, Lee TC, O'Gorman M, Judkins A, Cobrinik D, Triche TJ | display-authors = 6 | title = A Rapid and Sensitive Next-Generation Sequencing Method to Detect RB1 Mutations Improves Care for Retinoblastoma Patients and Their Families | journal = The Journal of Molecular Diagnostics | volume = 18 | issue = 4 | pages = 480–493 | date = July 2016 | pmid = 27155049 | pmc = 5820122 | doi = 10.1016/j.jmoldx.2016.02.006 }} Children with involvement of both eyes at diagnosis usually require multimodality therapy (chemotherapy, local therapies). [155] => [156] => The various treatment modalities for retinoblastoma includes: [157] => * [[Enucleation of the eye]] – Most patients with unilateral disease present with advanced intraocular disease, so usually undergo enucleation, which results in a cure rate of 95%. In bilateral Rb, enucleation is usually reserved for eyes that have failed all known effective therapies or without useful vision. [158] => * [[External beam radiotherapy]] (EBRT) – The most common indication for EBRT is for the eye in a young child with bilateral retinoblastoma who has active or recurrent disease after completion of chemotherapy and local therapies. However, patients with hereditary disease who received EBRT therapy are reported to have a 35% risk of second cancers.{{cite journal | vauthors = Roarty JD, McLean IW, Zimmerman LE | title = Incidence of second neoplasms in patients with bilateral retinoblastoma | journal = Ophthalmology | volume = 95 | issue = 11 | pages = 1583–1587 | date = November 1988 | pmid = 3211467 | doi = 10.1016/s0161-6420(88)32971-4 }} [159] => * [[Brachytherapy]] involves the placement of a radioactive implant (plaque), usually on the sclera adjacent to the base of a tumor. It used as the primary treatment, or more frequently, in patients with small tumors or in those who had failed initial therapy including previous EBRT therapy. [160] => * [[Thermotherapy]] involves the application of heat directly to the tumor, usually in the form of infrared radiation. It is also used for small tumors. [161] => * [[Laser photocoagulation]] is recommended only for small posterior tumors. An argon or diode laser or a xenon arc is used to coagulate all the blood supply to the tumor. [162] => * [[Cryotherapy]] induces damage to the vascular endothelium with secondary thrombosis and infarction of the tumor tissue by rapidly freezing it. It may be used as primary therapy for small peripheral tumors or for small recurrent tumors previously treated with other methods. [163] => * Systemic [[chemotherapy]] has become forefront of treatment in the past decade, in the search for globe-preserving measures and to avoid the adverse effects of EBRT therapy. The common indications for chemotherapy for intraocular retinoblastoma include tumors that are large and that cannot be treated with local therapies alone in children with bilateral tumors. It is also used in patients with unilateral disease when the tumors are small, but cannot be controlled with local therapies alone. [164] => * Intra-arterial chemotherapy – Chemotherapeutic drugs are administered locally by a thin catheter threaded through the groin, through the aorta, and the neck, directly into the optic vessels.{{cite journal | vauthors = Shields CL, Ramasubramanian A, Rosenwasser R, Shields JA | title = Superselective catheterization of the ophthalmic artery for intraarterial chemotherapy for retinoblastoma | journal = Retina | volume = 29 | issue = 8 | pages = 1207–1209 | date = September 2009 | pmid = 19734768 | doi = 10.1097/IAE.0b013e3181b4ce39 | s2cid = 47557934 }} [165] => * [[Nanomedicine|Nanoparticulate]] chemotherapy – To reduce the adverse effects of systemic therapy, subconjuctival (local) injection of [[nanoparticle]] carriers containing chemotherapeutic agents (carboplatin) has been developed, which has shown promising results in the treatment of retinoblastoma in animal models without adverse effects.{{cite journal | vauthors = Shome D, Poddar N, Sharma V, Sheorey U, Maru GB, Ingle A, Sarin R, Banavali S, Dikshit R, Jain V, Honavar S, Bellare J | display-authors = 6 | title = Does a nanomolecule of Carboplatin injected periocularly help in attaining higher intravitreal concentrations? | journal = Investigative Ophthalmology & Visual Science | volume = 50 | issue = 12 | pages = 5896–5900 | date = December 2009 | pmid = 19628744 | doi = 10.1167/iovs.09-3914 | s2cid = 7361361 }}{{cite journal | vauthors = Kang SJ, Durairaj C, Kompella UB, O'Brien JM, Grossniklaus HE | title = Subconjunctival nanoparticle carboplatin in the treatment of murine retinoblastoma | journal = Archives of Ophthalmology | volume = 127 | issue = 8 | pages = 1043–1047 | date = August 2009 | pmid = 19667343 | pmc = 2726977 | doi = 10.1001/archophthalmol.2009.185 }} [166] => * Chemoreduction is a combined approach using chemotherapy to initially reduce the size of the tumor, and adjuvant focal treatments, such as transpupillary thermotherapy, to control the tumor.{{cite journal | vauthors = Fabian ID, Johnson KP, Stacey AW, Sagoo MS, Reddy MA | title = Focal laser treatment in addition to chemotherapy for retinoblastoma | journal = The Cochrane Database of Systematic Reviews | volume = 2017 | issue = 6 | pages = CD012366 | date = June 2017 | pmid = 28589646 | pmc = 6481366 | doi = 10.1002/14651858.CD012366.pub2 }}{{cite journal | vauthors = Shields CL, Mashayekhi A, Cater J, Shelil A, Ness S, Meadows AT, Shields JA | title = Macular retinoblastoma managed with chemoreduction: analysis of tumor control with or without adjuvant thermotherapy in 68 tumors | journal = Archives of Ophthalmology | volume = 123 | issue = 6 | pages = 765–773 | date = June 2005 | pmid = 15955977 | doi = 10.1001/archopht.123.6.765 | doi-access = }} [167] => [168] => == Prognosis == [169] => In the developed world, retinoblastoma has one of the best cure rates of all childhood cancers (95-98%), with more than 90% of sufferers surviving into adulthood. In the UK, around 40 to 50 new cases are diagnosed each year.{{Cite journal |last1=Beddard |first1=N |last2=McGeechan |first2=GJ |last3=Taylor |first3=J |last4=Swainston |first4=K |date=2019 |title=Childhood eye cancer from a parental perspective: The lived experience of parents with children who have had retinoblastoma |journal=European Journal of Cancer Care |volume=29 |issue=2 |pages=e13209|doi=10.1111/ecc.13209 |pmid=31845431 |s2cid=196549559 |doi-access=free }} Good prognosis depends upon early presentation of the child in health facility.{{cite book |title=Concise ophthalmology : for medical students |date=2014 |publisher=Paramount Books |location=Karachi, Pakistan |isbn=9789696370017 |edition=4th | pages = 80–81 }} Late presentation is associated with a poor prognosis.{{cite journal | vauthors = Rai P, Shah IA, Narsani AK, Lohana MK, Memon MK, Memon MA | title = Too late presentation of 53 patients with retinoblastoma. | journal = International Journal of Ophthalmology | date = 2009 | volume = 9 | issue = 2 | pages = 227–230 | doi = }} Survivors of hereditary retinoblastoma have a higher risk of developing other cancers later in life. [170] => [171] => ==Epidemiology== [172] => Retinoblastoma presents with cumulative lifetime incidence rate of one case of retinoblastoma per 18000 to 30000 live births worldwide.{{cite journal | vauthors = Abramson DH, Schefler AC | title = Update on retinoblastoma | journal = Retina | volume = 24 | issue = 6 | pages = 828–848 | date = December 2004 | pmid = 15579980 | doi = 10.1097/00006982-200412000-00002 | s2cid = 26883037 }} A higher incidence is noted in developing countries, which has been attributed to lower socioeconomic status and the presence of [[human papilloma virus]] sequences in the retinoblastoma tissue.{{cite journal | vauthors = Orjuela M, Castaneda VP, Ridaura C, Lecona E, Leal C, Abramson DH, Orlow I, Gerald W, Cordon-Cardo C | display-authors = 6 | title = Presence of human papilloma virus in tumor tissue from children with retinoblastoma: an alternative mechanism for tumor development | journal = Clinical Cancer Research | volume = 6 | issue = 10 | pages = 4010–4016 | date = October 2000 | pmid = 11051250 }} [173] => [174] => Almost 80% of children with retinoblastoma are diagnosed before three years of age and diagnosis in children above six years of age is extremely rare.{{cite journal | vauthors = Abramson DH, Frank CM, Susman M, Whalen MP, Dunkel IJ, Boyd NW | title = Presenting signs of retinoblastoma | journal = The Journal of Pediatrics | volume = 132 | issue = 3 Pt 1 | pages = 505–508 | date = March 1998 | pmid = 9544909 | doi = 10.1016/s0022-3476(98)70028-9 }} In the UK, bilateral cases usually present within 14 to 16 months, while diagnosis of unilateral cases peaks between 24 and 30 months. [175] => [176] => == See also == [177] => * [[Eye cancer]] [178] => * [[Eye examination]] [179] => * [[Retinoblastoma protein]] [180] => [181] => == References == [182] => {{Reflist}} [183] => [184] => == External links == [185] => * [https://www.nlm.nih.gov/medlineplus/ency/article/001030.htm Retinoblastoma information] from [[MedlinePlus]] [186] => * {{GeneTests|retinoblastoma}} [187] => * [http://rb1-lsdb.d-lohmann.de/ RB1 Mutation Database] [188] => * {{Curlie|Health/Conditions_and_Diseases/Cancer/Eye/Retinoblastoma/}} [189] => * [https://www.ncbi.nlm.nih.gov/gtr/all/tests/?term=retinoblastoma/ NCBI Genetic Testing Registry] [190] => {{Medical resources [191] => | ICD10 = {{ICD10|C|69|2|c|69}} [192] => | ICD9 = {{ICD9|190.5}} [193] => | ICDO = {{ICDO|9510|3}} [194] => | OMIM = 180200 [195] => | MedlinePlus = 001030 [196] => | eMedicineSubj = oph [197] => | eMedicineTopic = 346 [198] => | DiseasesDB = 11434 [199] => | MeshID = D012175 [200] => | GeneReviewsNBK = NBK1452 [201] => | GeneReviewsName = Retinoblastoma [202] => }} [203] => [204] => {{Nervous tissue tumors}} [205] => {{Eye tumors}} [206] => [207] => [[Category:Ocular neoplasia]] [208] => [[Category:Rare diseases]] [209] => [[Category:Nervous system neoplasia]] [210] => [[Category:Hereditary cancers]] [211] => [[Category:Small-blue-round-cell tumors]] [212] => [[Category:Pediatric cancers]] [] => )
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Retinoblastoma

Retinoblastoma is a rare form of eye cancer that primarily affects young children. This Wikipedia page provides a comprehensive overview of the disease, covering its causes, symptoms, diagnosis, treatment options, prognosis, and preventive measures.

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This Wikipedia page provides a comprehensive overview of the disease, covering its causes, symptoms, diagnosis, treatment options, prognosis, and preventive measures. The page explains that retinoblastoma is caused by mutations in the RB1 gene, which is responsible for controlling cell growth in the retina. These mutations can be inherited or occur spontaneously. Symptoms of the disease include a white pupil reflex, eye pain, and redness, while risk factors include a family history of retinoblastoma or certain genetic conditions. Diagnosis of retinoblastoma typically involves a thorough eye examination, imaging tests, and a biopsy. The staging of the disease, which determines the extent of its spread, is also explained. The page goes on to discuss various treatment options, including chemotherapy, radiation therapy, laser therapy, cryotherapy, and surgery. It emphasizes the importance of a multidisciplinary team in providing personalized treatment plans for each patient. Prognosis for retinoblastoma varies depending on factors such as the stage and location of the tumor, age at diagnosis, and the presence of genetic mutations. The page highlights the importance of early detection and timely intervention for improving outcomes. It also mentions the potential long-term complications of the disease, such as vision loss and risk of additional tumors. Preventing retinoblastoma in individuals with a genetic predisposition is addressed, including genetic counseling and screening strategies. The page also provides information on support services and organizations that help patients and families dealing with retinoblastoma. Overall, this Wikipedia page provides a comprehensive and detailed overview of retinoblastoma, serving as a valuable resource for understanding the disease, its diagnosis, treatment options, and preventive measures.

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