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Original Investigation
December 2016

Minimal Disseminated Disease in Nonmetastatic Retinoblastoma With High-Risk Pathologic Features and Association With Disease-Free Survival

Author Affiliations
  • 1Hematology-Oncology Service, Pediatric Hospital S.A.M.I.C. Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
  • 2Pathology Service, Pediatric Hospital S.A.M.I.C. Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
  • 3Molecular Oncology Laboratory, Quilmes National University, Bernal, Buenos Aires, Argentina
  • 4Hospital Infantil de México Federico Gomez, Ciudad de México, Distrito Federal, México
  • 5Immunology Service, Pediatric Hospital S.A.M.I.C. Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
JAMA Ophthalmol. 2016;134(12):1374-1379. doi:10.1001/jamaophthalmol.2016.4158
Key Points

Question  Is minimal dissemination (MD) an effective tool for evaluating the extent of nonmetastatic retinoblastoma using quantitative polymerase chain reaction for the cone-rod homeobox transcription factor detected in cerebrospinal fluid or bone marrow in patients with high-risk pathologic features?

Findings  In this cohort study of 96 children with retinoblastoma and high-risk pathologic features, 9 presented with MD, which was more commonly found in those with scleral compromise or invasion of the resection margin of the optic nerve and those presenting with glaucoma. Patients with MD had a lower rate of disease-free survival.

Meaning  These data suggest that MD may be a tool for identifying higher-risk patients who need a more intensive approach.

Abstract

Importance  Fatal metastatic relapse may occur in children with retinoblastoma and high-risk pathologic features (HRPFs). Minimal dissemination (MD) may be an additional tool for risk estimation. The use of cone-rod homeobox (CRX) transcription factor messenger RNA for MD evaluation in metastatic retinoblastoma was previously reported, but no data in nonmetastatic cases with HRPFs are available.

Objectives  To evaluate whether MD is detectable in patients with nonmetastatic retinoblastoma and to assess its prognostic effect on disease-free survival (DFS).

Design, Setting, and Participants  This single-institution cohort study of patients with nonmetastatic retinoblastoma and HRPFs used prospectively defined inclusion criteria and a sampling strategy to procure bone marrow (BM) and cerebrospinal fluid (CSF) samples from May 1, 2007, through October 31, 2013. Median follow-up was 38 months (range, 8-89 months). Survival analysis was closed in December 2015, and no further updates were made after that point.

Interventions  The study evaluated CRX messenger RNA by quantitative polymerase chain reaction in BM and CSF at diagnosis and follow-up. In 14 patients, GD2 synthase was used instead of CRX for CSF evaluation. Patients were treated under uniform guidelines.

Main Outcomes and Measures  Metastatic relapse.

Results  The study included 96 children (median age at study inclusion, 26 months; range, 1-168 months; 46 male [47.9%]; 50 female [52.1%]) with nonmetastatic retinoblastoma and HRPFs (isolated massive choroidal invasion in 14, postlaminar optic nerve invasion in 51 [26 with concomitant massive choroidal and 13 with scleral invasion], 12 with scleral invasion without postlaminar optic nerve invasion, and 7 with tumor at the resection margin of the optic nerve) were evaluated at the time of primary or secondary enucleation. Minimal dissemination was detected in 9 patients (7 BM samples and 2 CSF samples) and was associated with extension beyond the resection margin of the optic nerve and scleral involvement, but only the former was independently associated (adjusted odds ratio, 57.0; 95% CI, 4.8-678.2; P = .001). In addition, MD occurred in 8 of the 43 International Intraocular Retinoblastoma Classification group E eyes with glaucoma (18.6%) and in 8 of 80 (10%) and 1 of 16 children (6.3%) who underwent primary or secondary enucleation, respectively. Children with MD had a 3-year DFS of 0.78 compared with 0.98 in those without MD (95% CI for the difference in DFS, 0.17-0.23; P = .004).

Conclusions and Relevance  These findings identified a high-risk population of children with retinoblastoma and HRPFs with MD. Because the number of events was small, these results, which suggest that children with International Intraocular Retinoblastoma Classification group E retinoblastoma and glaucoma have a higher risk of MD at diagnosis, should not be considered definitive at this time.

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